As with the study by Kovacs et al. This is a pulmonary embolism (PE). In the intervention group, patients were treated at home if the NT-proBNP was normal but hospitalized in case of elevated NT-proBNP levels.7  Only 12% of those randomized to NT-proBNP testing had elevated levels and were hospitalized. For instance, it was estimated that at least 25% of patients admitted for PE in the United States could be treated at home. The most likely explanation for the low number of patients with elevated NT-proBNP is that the Hestia rule preselects patients with normal NT-proBNP levels.7, The eSPEED study was a controlled pragmatic trial designed to evaluate the effect of an integrated electronic clinical decision support system to facilitate risk stratification and decision making at the site of care for patients with acute PE.8  The PESI was used as primary risk stratification tool. After the intervention, the proportion of patients treated at home increased considerably, with a relative increase of 61% (18% preintervention to 28% postintervention), whereas no change was found in the control sites (15% preintervention and 14% postintervention). AU - Banala, Srinivas R. AU - Yeung, Sai Ching Jim. When establishing a PE outpatient pathway, 2 major decisions must be made. Vasodilators: Vasodilators may improve blood flow by … In summary, the present prospective observational cohort study has shown that highly selected patients with pulmonary embolism can be managed by early discharge from hospital once the diagnosis has been confirmed. The first one concerns the selection of patients for home treatment. As a significant proportion of patients with DVT also have silent PE (as defined by high-probability V’/Q’ scans) 3–6, it is likely that many patients who receive outpatient treatment for DVT have also received outpatient treatment of PE. Enter multiple addresses on separate lines or separate them with commas. Clinical guidelines recommend early discharge of patients with low-risk pulmonary embolism (LRPE). A specialized nurse evaluated the initial course of disease, presence of complications, and risk factors for complications (eg, by measuring blood pressure and checking medication adherence). If PESI is used, parameters of the hemodynamic profile of the patients are included in the risk stratification, but RV function is not. Davies*, J. Wimperis#, E.S. Emergency department management of incidental pulmonary embolism in patients with cancer: a retrospective study Int J Emerg Med. This study measured the overall impact of early discharge of LRPE patients on clinical outcomes and costs in the Veterans Health Administration population. Importantly, no increases were seen in 5-day return visits related to PE and in 30-day major adverse outcomes associated with clinical decision support system implementation: 12% (95% CI, 5.6-22) vs 6.2% (95% CI, 2.7-12) at the intervention sites vs 9.8% (95% CI, 3.7-20) and 5.1% (95% CI, 1.1-14) at the control sites, respectively.8, In the Low-Risk Pulmonary Embolism Prospective Management Study, 200 patients considered to have low-risk PE based on PESI (class I or II), echocardiography (no signs of right heart strain on echocardiogram), and whole-leg ultrasound of the legs (no proximal deep vein thrombosis) were treated at home with a direct oral anticoagulant.9  Of the 1003 screened patients, 213 were in PESI class I or II and had no other exclusion criteria. Her physical examination and electrocardiogram were unremarkable. The initial outpatient DVT studies were interpreted with caution, but further studies confirmed both the safety and acceptability of outpatient DVT management, permitting ≤91% of patients to be managed without admission 10, 11, 14, 23. When establishing a PE outpatient pathway, 2 major decisions must be made. Home treatment is feasible and safe in selected patients with acute pulmonary embolism (PE) and is associated with a considerable reduction in health care costs. M.V.H. The 3-month incidence of recurrent VTE in these latter patients was 2.0% (95% confidence interval [CI], 0.8-4.3), of vitamin K antagonist–associated major bleeding was 0.7% (95% CI, 0.08-2.4), of PE-associated mortality was 0% (95% CI, 0-1.2), and of overall mortality was 1.0% (95% CI, 0.2-2.9). Go to follow-up appointments and take blood thinners as directed. You may urinate more often when you take this medicine. Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard. This is a very reasonable approach in practice-based conditions as well. Ultimately, these adverse outcome scores and other criteria, such as those derived from the present study and that by Kovacs et al. The first one concerns the selection of patients for home treatment. The incidence of recurrent VTE was also comparable between the 2 groups: 1.1% (95% CI, 0.2-3.2) for those in the standard of care arm vs 0.73% (95% CI, 0.1-2.6) in the NT-proBNP arm of the study. Epub 2017 Jun 6. Pulmonary embolism can be very serious. In the literature, outpatient management of acute PE has been referred to as home treatment, early discharge, and outpatient treatment, although a clear definition is lacking. Eur Heart J. The study by Kovacs et al. Of the approximately 900,000 annual venous thromboembolism (VTE) events occurring in the United States, 1 it is estimated that more than 250,000 are diagnosed with pulmonary embolus in the emergency department (ED). The primary efficacy outcome was symptomatic recurrent VTE or PE-related death within 3 months of enrolment, which occurred in 0.6% of patients.10  The incidence of major bleeding was 1.2%, and 2.3% of patients required hospitalization because of (suspected) PE-related complications. A similar level of support should be possible in centres wishing to implement outpatient anticoagulation therapy for PE using existing DVT nurse-led services and on-call medical staff. I f a patient shows up in the emergency department with a pulmonary embolism (PE), is it safe to send him home? Mostly, however, the health care costs are much lower if (unnecessary) admission is prevented. Medical or social reason for treatment in the hospital for more than 24 h (infection, malignancy, no support system)? You will probably take a prescription blood-thinning medicine to prevent blood clots. Because of this, major regional differences can be observed. Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Mortality risk: class I (<65 points), very low risk; class II (66-85 points), low risk; class III (86-105 points), intermediate risk; class IV (106-125 points), high risk; class V (>125 points): very high risk. The VESTA study was a noninferiority trial in which 550 patients with acute PE and none of the Hestia criteria were randomized between immediate home treatment and advanced risk stratification via n-terminal pro-brain natriuretic peptide testing. Second, in most studies, patients were contacted by telephone or evaluated in an outpatient clinic in the first week after diagnosis. Such patients may even prefer being at home surrounded by relatives over hospital admission. Discharging those patients from the emergency ward would decrease health care costs by an estimated $1 billion each year.15  In the Dutch setting, a recent post hoc analysis of the YEARS study identified a net cost reduction of €1.500 for each patient treated at home. Where possible, all potential patients with PE were notified by medical staff from the different teams caring for these patients and by liaison with radiological staff. Although phase 1 of the present study was able to capture all suspected and subsequently confirmed patients with PE, it is known that this was not achieved in consecutive patients in all centres during phase 2, which is a weakness of the study. Discussion . Adverse outcome scores may help to predict the risk of adverse outcome from PE in treated patients. In the present study, a specific level of oxygen required to maintain oxygen saturation was not defined and, instead, anyone requiring ongoing oxygen therapy for dyspnoea and/or hypoxaemia as felt by the managing technician was excluded. When to call your healthcare provider Call your healthcare provider right away if you have: Pain, swelling, and redness in your leg, arm, or other body area. The severity of the PE and risk of adverse outcomes should largely determine clinical decision making with regard to initial home treatment. AU - Alagappan, Kumar. A randomized clinical trial, eSPEED Investigators of the KP CREST Network, Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial, Management of low-risk pulmonary embolism patients without hospitalization: the Low-Risk Pulmonary Embolism Prospective Management Study, Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial, Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis, Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study, Home treatment of acute pulmonary embolism: state of the art in 2018, Home treatment of pulmonary embolism in the era of novel oral anticoagulants, Unnecessary hospitalizations for pulmonary embolism: impact on US health care costs, Safety of outpatient treatment in acute pulmonary embolism, Home treatment of patients with cancer-associated venous thromboembolism: An evaluation of daily practice, Current practice patterns of outpatient management of acute pulmonary embolism: A post-hoc analysis of the YEARS study, Pulmonary embolism, acute coronary syndrome and ischemic stroke in the Spanish National Discharge Database, La maladie veineuse thromboembolique: patients hospitalisés et mortalité en France en 2010, Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis, Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism, Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model, 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS), Right ventricle to left ventricle diameter ratio measurement seems to have no role in low risk patients with pulmonary embolism treated at home triaged by Hestia criteria, Uncertain value of high-sensitive troponin T for selecting patients with acute pulmonary embolism for outpatient treatment by Hestia criteria [published online ahead of print 12 March 2020], How I assess and manage the risk of bleeding in patients treated for venous thromboembolism, Prediction of bleeding events in patients with venous thromboembolism on stable anticoagulation treatment, Predicting anticoagulant-related bleeding in patients with venous thromboembolism: a clinically oriented review. 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