Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization

Bledsoe, Joseph; Woller, Scott C.; Stevens, Scott M.; Aston, Valerie; Patten, Rich; Allen, Todd L.; Horne, Benjamin D.; Dong, Lydia; Lloyd, James F.; Snow, Greg; Madsen, Troy; Elliott, C. Gregory

doi:10.1016/j.chest.2018.01.035

Cited by 67 publications

(31 citation statements)

References 59 publications

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“…While the safety of this practice was unclear and controversial just a few years ago [ 20 , 21 ], it has recently become more common with the increased use of direct-acting oral anticoagulants [ 22 , 23 ] and safety research in the field [ 24 , 25 ]. This is particularly true in large health care systems with tertiary EDs that can safely assess patients’ risk with bedside echocardiography and lower-extremity ultrasound [ 26 ]. Future studies will link CTPA scans to both inpatient and ED visits to improve the accuracy.…”

Section: Discussionmentioning

confidence: 99%

A Computerized Method for Measuring Computed Tomography Pulmonary Angiography Yield in the Emergency Department: Validation Study

et al. 2018

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BackgroundUse of computed tomography pulmonary angiography (CTPA) in the assessment of pulmonary embolism (PE) has markedly increased over the past two decades. While this technology has improved the accuracy of radiological testing for PE, CTPA also carries the risk of substantial iatrogenic harm. Each CTPA carries a 14% risk of contrast-induced nephropathy and a lifetime malignancy risk that can be as high as 2.76%. The appropriate use of CTPA can be estimated by monitoring the CTPA yield, the percentage of tests positive for PE. This is the first study to propose and validate a computerized method for measuring the CTPA yield in the emergency department (ED).ObjectiveThe objective of our study was to assess the validity of a novel computerized method of calculating the CTPA yield in the ED.MethodsThe electronic health record databases at two tertiary care academic hospitals were queried for CTPA orders completed in the ED over 1-month periods. These visits were linked with an inpatient admission with a discharge diagnosis of PE based on the International Classification of Diseases codes. The computerized the CTPA yield was calculated as the number of CTPA orders with an associated inpatient discharge diagnosis of PE divided by the total number of orders for completed CTPA. This computerized method was then validated by 2 independent reviewers performing a manual chart review, which included reading the free-text radiology reports for each CTPA.ResultsA total of 349 CTPA orders were completed during the 1-month periods at the two institutions. Of them, acute PE was diagnosed on CTPA in 28 studies, with a CTPA yield of 7.7%. The computerized method correctly identified 27 of 28 scans positive for PE. The one discordant scan was tied to a patient who was discharged directly from the ED and, as a result, never received an inpatient discharge diagnosis.ConclusionsThis is the first successful validation study of a computerized method for calculating the CTPA yield in the ED. This method for data extraction allows for an accurate determination of the CTPA yield and is more efficient than manual chart review. With this ability, health care systems can monitor the appropriate use of CTPA and the effect of interventions to reduce overuse and decrease preventable iatrogenic harm.

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Section: Discussionmentioning

confidence: 99%

A Computerized Method for Measuring Computed Tomography Pulmonary Angiography Yield in the Emergency Department: Validation Study

et al. 2018

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“…Such a time frame is similar to that used in other prospective studies of outpatient PE management. 1 , 2 , 17 , 23 Two RAs contacted eligible patients for telephone interviews. To communicate directly with patients who were hard of hearing, the California Relay Service line was used.…”

Section: Methodsmentioning

confidence: 99%

“…31 Some studies of expedited discharge of ED PE patients have conducted their patient-satisfaction surveys at 90 days. 17 There are also potential generalizability limitations due to the exclusion of non-English speakers. Additionally, the effects of differences in select patient characteristics between the cohorts could be further analyzed.…”

Section: Limitationsmentioning

confidence: 99%

“… 14 , 15 Limited research has been conducted focusing exclusively on patients with PE, although existing research indicates that outpatient management of PE has been satisfactory. 1 , 16 , 17 Patients with other conditions, such as community-acquired pneumonia and stroke, have also reported comparable or improved satisfaction and QOL scores following outpatient management, compared to inpatient treatment. 18 – 20 However, to our knowledge, little has been done to examine the effects of length of stay (LOS) within a population of low-risk PE patients.…”

Section: Introductionmentioning

confidence: 99%

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Emergency Department Patient Satisfaction with Treatment of Low-risk Pulmonary Embolism

Simon

Iskin

Vemula

et al. 2018

WestJEM

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IntroductionMany emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I–III).MethodsThis phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2–8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated.ResultsSurvey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all).ConclusionED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.

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“…Until recently, outpatient care has mainly been reserved for investigation and management of deep vein thrombosis. For people with both suspected and confirmed pulmonary embolism, new evidence supports ambulatory care for those at low risk of complication, assessed by validated tools 91011…”

Section: Recommendationsmentioning

confidence: 99%

Venous thromboembolism in adults: summary of updated NICE guidance on diagnosis, management, and thrombophilia testing

McCormack

Harrisingh

Horner

et al. 2020

BMJ

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Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization

Cited by 67 publications

References 59 publications

A Computerized Method for Measuring Computed Tomography Pulmonary Angiography Yield in the Emergency Department: Validation Study

A Computerized Method for Measuring Computed Tomography Pulmonary Angiography Yield in the Emergency Department: Validation Study

Emergency Department Patient Satisfaction with Treatment of Low-risk Pulmonary Embolism

Venous thromboembolism in adults: summary of updated NICE guidance on diagnosis, management, and thrombophilia testing

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