RESULTS
The original population for analysis contained 512 admissions to our institution . There were 340 exclusions due to the following conditions : pregnancy , chronic kidney disease stages 4 and 5 , ICU patients , those with a BMI 40 or greater or a BMI could not be determined , active bleeding , thrombocytopenia , anemia , those presenting with chest pain , cardiac arrest in progress , severe dementia , metastatic cancer , falls , and refusals and noncompliant patients . After exclusions , a population of 255 patient admissions remained for analysis . Demographics for the study population included 50.6 % females and 49.4 % males . The median age was 71 years ( range 21 – 99 ), with 23 % being 80 years or older . The mean population BMI was 28 ± 5.6 . Comorbidities in the study population included diabetes mellitus ( 40 %), chronic obstructive pulmonary disease ( COPD ) or interstitial lung disease ( 44 %), asthma ( 6 %), hypertension ( 78 %), active cancer ( 11 %), rheumatoid arthritis ( 2.4 %), immunocompromised without human immunodeficiency virus ( 16 %), stage 3 chronic kidney disease ( 39 %), and cirrhosis of the liver resulting from nonalcoholic steatohepatitis , viral , or cancer ( 4 %). Heart failure was present in 23 %, while those with a history of cardiovascular disease , including a prior cardiac catheterization , transcatheter cardiovascular therapeutics , coronary artery stent , coronary artery bypass surgery , or myocardial infarction , encompassed 37 % of the population . The proportion admitting tobacco smoking in the last 30 days was 24 %. Of the 12 comorbidities collected , the median number of comorbidities for subjects was three and ranged from zero to seven .
Group A , whose treatment was determined to be consistent with current guidelines was 58.8 % ( n = 150 ), while Group B were patients who received treatment not consistent with guidelines was 41.2 % ( n = 105 ) ( Table 1 ). Only stage 3 chronic kidney disease ( GFR 30-59 ml / min ) was significantly different ( p < . 001 ) between the two groups , with Group B having the highest proportion of patients ( 39.0 %). Of all other comorbidities , these were found to be nonsignificant , as shown in Table 1 .
DISCUSSION
Our study aimed to examine the treatment patterns of antithrombotic therapies in non-critically ill COVID-19 patients at our institution in relation to the recently published guidelines . The COVID-19 pandemic presented a unique challenge for physicians , and the guidelines regarding antithrombotic use for these COVID-19 patients have been a welcomed addition to complex clinical treatment . However , our study revealed an opportunity for improvement between those receiving treatment consistent with guidelines and those who did not . Undoubtedly , patients in this population are complex in their medical history and presenting constellations of comorbidities along with their COVID-19 diagnosis . Increasing the challenge of providing care is the reality of economically depressed rural service areas within West Virginia and the unique challenges of caring for an elderly population . However , because of the risk for adverse events from UFH , the use of LMWH is the preferred antithrombotic in most COVID-19 and non-COVID-19 patients . The disadvantages of inter-individual dose requirements with IV UFH make close lab therapeutic monitoring necessary . The sensitivity of different activated partial thromboplastin clotting time ( aPTT ) reagents to UFH varies substantially along with the higher risk of HIT . With many of these patients presenting with sepsis , even those treated in a non-ICU setting , detection of suspicious declines in platelet counts indicating a suspicion of a HIT component could be easily missed placing an already high-risk patient population at even higher risk for a thromboembolic event or organ failure . Additionally , many observational studies have shown that in routine clinical settings , the need for frequent blood sticks , which are painful for patients , increases the chance of significant delay in getting partial thromboplastin time into the therapeutic range .
Limitations of this study include that it is retrospective with a relatively small number of eligible patients . In addition , many cases were excluded for bleeding conditions , extremes in BMI , chronic kidney disease stages 4 and 5 , and patients with a clinical scenario where UFH was potentially a safer and more beneficial option .
CONCLUSION
Clinical guidelines are commonplace for many conditions in the medical literature . However , the publication of guidelines leading to meaningful clinical adaptation can be delayed . Our study highlights how easily this can occur even in teaching hospitals where the translation of evidence-based care into everyday clinical practice is a challenge . This study revealed an opportunity for rigorous reinforcement of guideline education and rationale for their use in daily rounds . We could not distinguish a common characteristic identifying patients at risk for non-adherence to guidelines . This study could be used to justify a robust quality improvement initiative around antithrombic guidelines not only in this population but patients with other high-risk conditions .
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