Triage of patients with venous and lymphatic diseases during the COVID-19 pandemic – The Venous and Lymphatic Triage and Acuity Scale (VELTAS):

Abstract

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semiurgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/nonurgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.

Background

The global coronavirus disease 2019 (COVID-19) pandemic has resulted in diversion of healthcare resources including workforce, critical supplies, emergency and intensive care unit (ICU) facilities and personal protective equipment (PPE) to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic.¹ Limitations on direct personal contact and physical (social) distancing have influenced access to care and how it is provided. Patients with venous and lymphatic disorders or vascular anomalies continue to need expert care within current public health constraints. In addition, there is growing evidence that COVID-19 may predispose patients to both arterial and venous thromboembolic (VTE) disease and extensive coagulopathies further complicating the prognosis of the affected patients.2, 3, 4 To facilitate triage in this demanding setting we recommend the use of a standardised scale to rationalise and harmonise the management of these patients during this difficult period.

Aims

The Venous and Lymphatic Triage and Acuity Scale (VELTAS) was developed to provide an international standard for the triage of patients with venous and lymphatic disorders or vascular anomalies. VELTAS aims to improve patient safety and increase triage reliability by providing a standardised framework for the management of these conditions.

Methods

Stratification of triage urgency

Triage urgency is defined as the clinical assessment of urgency with which a patient would require medical treatment or surgical intervention.⁵ The principle for triage and prioritisation for admission for medical treatment or procedural interventions and surgery is based on the natural history and expected clinical outcomes of the condition, the rate of progression and deterioration, and the complications that may arise should treatment be delayed or withheld.⁶ The rationale for triage is ‘to do the greatest good for the greatest number’.⁷

Various models and strategies for stratifying urgency during the COVID-19 pandemic have been proposed.8, 9, 10 In this document, the appropriate timeline to attend to individual conditions was determined by an international panel of vascular experts.

The consensus process

The project was initiated by the International Union of Phlebology (UIP) in conjunction with the Australasian College of Phlebology. The document was written by the primary authors and further reviewed and developed by the co-editors, based on appraisal of current evidence in the literature published in print or online through April 2020. When evidence was lacking or limited, consensus was developed. The document was shared with an international expert panel of phlebologists and vascular specialists representing the endorsing societies and further topics and recommendations were included and the final document formulated. Consensus on triage and acuity was reached when a recommendation was unanimously supported by all authors. In case of any dissenting opinion multiple attempts were made to modify the recommendation. At the end of the consensus process, all participating authors approved the final version of the document and agreed to be accountable for all aspects of the work.

Utility and target audience

The scale is designed primarily for phlebologists and vascular specialists but will be also useful for primary physicians and general practitioners, referring doctors, emergency specialists and other healthcare professionals and health policymakers. VELTAS will be especially relevant during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.

Scope

The scale includes a comprehensive range of conditions seen by phlebologists and other vascular specialists involved in the management of patients with venous and lymphatic disorders or vascular anomalies as defined by the UIP curriculum.¹¹

Recommendations

Clinical conditions within the scope of phlebology were classified into six categories of (1) VTE, (2) chronic venous disease (CVD), (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency in each clinical category was classified into four groups of (1) medical emergencies, (2) urgent, (3) semiurgent and (4) discretionary/nonurgent. Individual conditions in each clinical category were allocated to a class of triage by the expert panel (Table ).

Table.

Venous and Lymphatic Triage and Acuity Scale (VELTAS)

Triage	Acuity	Priority	Clinical categories	Indications for medical treatmenta or interventionb
Medical emergency	Acute	Immediate	VTE	− Massive PE with or without DVT − Acute iliofemoral DVT with phlegmasia9 or sepsis − Acute ASVT with phlegmasia − Acute central vein thrombosis with superior vena cava syndrome − Acute MVT with peritonitis − Acute paradoxical embolism and stroke10 − Venous gangrene
	Life-threatening		CVD	− Life-threatening blood loss10 from a bleeding varix − Acute septicaemia or uncontrolled sepsis in a leg wound
	Potential for immediate deterioration		Vascular anomaliesc	− Kasabach-Merrit syndrome with severe coagulopathy − Severe cardiac failure secondary to AVM
			Venous trauma	− Life or limb-threatening venous trauma10
			Lymphatic disease	− Acute septicaemia or uncontrolled lymphangitis or secondary infection
Category 1	Acute	As soon as possible	VTE	− PE,10 DVT, ASVT, MVT or extensive proximal SVTd12,13 − DVT requiring IVC filter placement14 − Acute central vein thrombosis with or without haemodialysis access
Urgent	Potential to be life-threatening	Initial management may be provided by the referring doctor	CVD	− Temporarily controlled bleeding varices − Infected wounds and ulcers with risk of septicaemia − Squamous cell carcinoma in a venous ulcer
	Potential to deteriorate quickly and may become an emergency	Consider urgent tele-interview	Vascular anomaliesc	− Acute complications including infection, bleeding and thrombosis − Cardiac failure secondary to AVM − Vascular malignancies
			Venous trauma	− Nonlife or limb-threatening venous trauma
			Lymphatic disease	− Lymphoedema with extensive lymphangitis or secondary cellulitis and risk of septicaemia
Category 2	May be chronic or new onset	Within 30-90 days	VTE	− Symptomatic nonextensive SVTd − Removal of IVC retrievable filters14
Semiurgent	Unlikely to become an emergency	Initial management by the referring doctor	CVD	− CEAP15 C3–C6e − Highly symptomatic CVD (irrespective of CEAP classification)e − Highly symptomatic pelvic venous insufficiency, varicocelesf
	Unlikely to deteriorate quickly	Consider tele-interview	Vascular anomaliesc	− Complex or extensive vascular tumours and malformations − LIC within a vascular malformation or tumour − Ulceration and cutaneous complications
	Highly symptomatic can cause significant pain, dysfunction or disability		Venous compression	− Highly symptomatic venous compression syndromesf
			Lymphatic disease	− Chronic lymphoedema with secondary infection or cutaneous changes
Category 3	Chronic	Within 6-12 months	VTE	− Chronic symptomatic post-thrombotic obstruction
Discretionary/ nonurgent	No apparent potential to become an emergency	Initial management by the referring doctor	CVD	− CEAP C0S–C2e − Mildly symptomatic pelvic venous insufficiency, varicocelesf
	Slow progression	Consider tele-interview	Vascular Anomaliesc	− Uncomplicated benign vascular tumours and malformations
	Asymptomatic or mildly symptomatic		Venous compression	− Venous TOS − Mildly symptomatic venous compression syndromes including May–Thurner syndromef
			Lymphatic disease	− Chronic lymphoedema or lipoedema

ASVT, Acute axillary subclavian vein thrombosis; AVM, arteriovenous malformation; CEAP, Clinical, Etiological, Anatomical, Pathophysiology classification; CVD, chronic venous disease; DVT, deep vein thrombosis; IVC, inferior vena cava; LIC, localised intravascular coagulopathy; MVT, mesenteric vein thrombosis; PE, pulmonary embolism; SVT, superficial vein thrombosis; TOS, thoracic outlet syndrome; VTE, venous thromboembolism.

^aMedical treatment started at admission may be continued in an outpatient setting.

^bIntervention can be performed in a nonhospital ambulatory or outpatient setting.

^cVascular anomalies incorporate two broad categories of vascular tumours such as haemangiomas and vascular malformations. The latter further includes venous (VM), arteriovenous (AVM), lymphatic (LM), capillary (CM), combined, complex and syndromic malformations in adults and children.

^dExtensive SVT is defined as above-knee great saphenous SVT ≥5 cm long whilst nonextensive SVT is defined as nonsaphenous SVT, below-knee saphenous SVT or above-knee saphenous SVT <5 cm in length.

^eDuring pandemic circumstances, CVD should be initially managed in the community with a trial of medical treatments including compression therapy if appropriate; advice from vascular specialists to be obtained using tele-health technology where available.

^fThis indication excludes asymptomatic patients from triage categories and includes symptomatic patients only, as there is no current indication to intervene for asymptomatic May–Thurner syndrome, other venous compression syndromes or asymptomatic pelvic venous insufficiency.

Adaptation to pandemic circumstances

We recognise that clinical practice and expectations need to be adapted in times of regional or global crisis. Under pandemic circumstances patients are encouraged to continue to consult their general practitioners and primary care physicians via appropriate means such as tele-health facilities to initiate management and to obtain a referral to phlebologists or other vascular specialists when necessary. During the pandemic, tele-health facilities should be used by treating specialists as much as possible to address patients concerns and provide advice on treatment options. Medical emergencies should continue to be triaged by emergency services where available.

Additional comments and exclusions

• (1)This document should be used as a general guideline applicable to both hospital and nonhospital ambulatory settings.
• (2)Decisions regarding clinical urgency need to consider the patients' individual circumstances and loco-regional variations in the clinical practice of medicine, hospital policies and government-enforced guidelines and directives.
• (3)
  In developing VELTAS we recognise and acknowledge that some conditions:

  • (i)
    can be managed differently;
  • (ii)
    can be managed completely or in part by a variety of other healthcare providers;
  • (iii)
    are less urgent and hence can be managed more conservatively;
  • (iv)
    when chronic, can be safely delayed for definitive procedural interventions; and
  • (v)
    must be dealt with just as promptly despite the pandemic.
• (4)The scale does not replace the treating physician's clinical judgement of acuity and severity and the requirement for intervention as applicable in different models of healthcare.
• (5)The specified times for attendance indicate the ideal time frames within which patients should be seen and attended to. Such ideal timelines may be influenced by other factors such as availability of resources, other competing national or regional requirements for critical supplies and PPE, and national, regional, local and individual hospital admission policies.
• (6)This document should not be used to delay or deny treatment of less urgent cases, deny or minimise reimbursement for services provided, or limit access to healthcare when resources are not limited, and such care does not present a risk to patients or health care workers.

Conclusions

VELTAS is a triage and acuity scale dedicated to the care of patients with acute and chronic venous and lymphatic disorders or vascular anomalies. The scale aims to standardise the triage of this group of patients by providing a consensus-based classification of clinical categories and triage urgency.

Author contributions

Conception and design: KP

Analysis and interpretation: KP, AvR, MM, AD, MDM, PG, SB, OB, VMC, PD, AG, SG, DH, DJ, BL, LK, AL, WM, AMG, NM, AN, PP, MP, SR, CR, MS, PK, AS, ST, RV, HW, CW

Data collection: Not applicable

Writing the article: KP, AvR, MM, MDM, PG

Critical revision of the article: KP, AvR, MM, AD, MDM, PG, SB, OB, VMC, PD, AG, SG, DH, DJ, BL, LK, AL, WM, AMG, NM, AN, PP, MP, SR, CR, MS, PK, AS, ST, RV, HW, CW

Final approval of the article: KP, AvR, MM, AD, MDM, PG, SB, OB, VMC, PD, AG, SG, DH, DJ, BL, LK, AL, WM, AMG, NM, AN, PP, MP, SR, CR, MS, PK, AS, ST, RV, HW, CW

Statistical analysis: Not applicable

Obtained funding: Not applicable

Overall responsibility: KP

KP and AvR participated equally and share co-first authorship.