Early discharge and outpatient management of pulmonary embolism appears safe and acceptable in selected low-risk patients, and can be implemented using existing outpatient deep venous thrombosis services. Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. Enter multiple addresses on separate lines or separate them with commas. Previous smaller studies have also identified subgroups of PE patients who appeared to be suitable for safe outpatient management of PE. Discussion . The second one involves dedicated outpatient follow-up including sufficient patient education and facilities for specialized follow-up visits. Sign In to Email Alerts with your Email Address, Early discharge of patients with pulmonary embolism: a two-phase observational study, Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. In general, outpatient pathways should be collaborative between general practitioners and thrombosis specialists, including fast exchange of a medical reports and/or discharge letters to all involved.30. Other adverse outcomes such as death from comorbidities (eg, advanced cancer) within the first weeks after diagnosis can, however, not be prevented by hospital admission. Second, in most studies, patients were contacted by telephone or evaluated in an outpatient clinic in the first week after diagnosis. If the answer to one of the questions is yes, the patient cannot be treated at home in the Hestia Study. Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard. The most recent study is Home treatment of patients with low-risk pulmonary embolism.10 In total, 525 of 2854 screened patients with acute PE were treated with rivaroxaban and discharged early in the absence of any of the Hestia criteria, signs of RV dysfunction or free-floating thrombi in the right atrium or RV, and contraindications to rivaroxaban. N2 - Background: … In the Outpatient Treatment of Pulmonary Embolism study, 344 PE patients (1557 screened for eligibility) were randomized to home treatment or hospitalization.5 First, the Pulmonary Embolism Severity Index (PESI) score was used to identify patients with low mortality risk (Table 1): only patients with PESI class I and II were considered suitable for home treatment. Indeed, several large studies have been performed showing the safety of home treated PE patients and its benefits with regard to health care costs and patient satisfaction.5-11 Here, we describe the current state of the art of selecting PE patients for home treatment and best practices with regard to PE outpatient pathways. Go to follow-up appointments and take blood thinners as directed. Discharge Instructions for Pulmonary Embolism. The patient remained clinically stable during the following days, allowing a progressive reduction of the flow. Her temperature was 37.2°C, heart rate was 85 beats/min, respiratory rate was 14 breaths/min, oxygen saturation at room air was 98%, and blood pressure was 136/72 mm Hg. The median length of hospitalization was 34 hours, and 12% of patients were discharged directly on confirmation of the PE diagnosis. She reported no provoking factors for PE nor symptoms suggestive of deep vein thrombosis. Case summary Two patients with positive RT-PCR test were initially hospitalized for non-severe COVID-19. Pulmonary embolism (PE) is a major cause of admission to hospital, with an incidence of ∼23 per 100,000 population 1, 2.Since PE and deep venous thrombosis (DVT) often coexist as venous thromboembolism (VTE), many patients presenting with symptomatic DVT have asymptomatic pulmonary emboli and vice versa 3–6.The management of VTE is now well established, with an initial … patient−1. Pulmonary embolism is very serious and may cause death if the clot is large or there are multiple clots. A pulmonary embolism (PE) is caused by a blood clot that gets stuck in an artery in your lungs.That blockage can damage your lungs and hurt other … Does the patient have a documented history of heparin-induced thrombocytopenia. Rivaroxaban was given at the approved dose for treatment of venous thromboembolism (VTE)/PE for at least 3 months. We report two cases of COVID-19 patients developing acute pulmonary embolism (PE) after discharge from a first hospitalization for pneumonia of moderate severity. In absence of an alternative explanation, 1 YEARS item was awarded (PE most likely diagnosis), and a d-dimer test was ordered.12 Because the d-dimer level was above the threshold (782 ng/mL; threshold, 500 ng/mL), a computed tomography pulmonary angiography was ordered showing a segmental PE in the left lower lobe. Epub 2017 Jun 6. 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. Does the patient have severe liver impairment? The results from phase 1 suggested that early discharge and outpatient anticoagulation therapy may be suitable for nearly half of all patients with confirmed PE. Outpatient treatment after early discharge was highly acceptable to patients, and use of once-daily tinzaparin required no significant laboratory monitoring. Both home treatment and early discharge involve a much shorter hospitalization than the 7 to 14 days that has been described as the mean admission duration in several European countries.13 In the United States, the median duration of hospital admission for PE was reported to be close to a week.14. Patients at risk for such complications should be hospitalized. Of those, 13 met 1 of the imaging exclusion criteria. T1 - Discharge or admit? After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. It may be unnecessary to exclude these patients in future treatment protocols. Current evidence points toward the use of either the Hestia criteria or Pulmonary Embolism Severity Index with/without assessment of the right ventricular function to select patients for home treatment, depending on local preferences. More than 24 h of oxygen supply to maintain oxygen saturation > 90%? This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. All 5 patients … 2 In a U.S. National Hospital Ambulatory Medical Care Survey analysis, during 2006 to 2010, >90% of ED patients diagnosed with pulmonary embolism (PE) were hospitalized. Emergency department management of incidental pulmonary embolism in patients with cancer. The Pulmonary Embolism Severity Index (PESI) predicts 30-day outcome of patients with pulmonary embolism using 11 clinical criteria. Keely MA. 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. The first one concerns the selection of patients for home treatment. Hence, in our practice, we use the Hestia criteria without further explicit (imaging) biomarkers. You may urinate more often when you take this medicine. Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. European Respiratory Society442 Glossop RoadSheffield S10 2PXUnited KingdomTel: +44 114 2672860Email: journals@ersnet.org, Print ISSN: 0903-1936 Cambron JC, Saba ES, McBane RD, et al; Adverse Events and Mortality in Anticoagulated Patients with Different Categories of Pulmonary Embolism. Because of this, major regional differences can be observed. 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. Search for other works by this author on: Management of intermediate-risk pulmonary embolism: uncertainties and challenges, 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC), Trends in mortality related to pulmonary embolism in the European Region, 2000-15: analysis of vital registration data from the WHO Mortality Database, Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial, Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study, Efficacy and safety of outpatient treatment based on the hestia clinical decision rule with or without N-terminal pro-brain natriuretic peptide testing in patients with acute pulmonary embolism. In the last decade, several landmark studies have been published, demonstrating the safety of home treatment in selected low-risk PE patients. The protocol in many hospitals says absolutely not: The vast majority of PE patients are routinely admitted for several days to monitor their condition and supervise the start of anticoagulants. Does the patient have a creatinine clearance of < 30 mL/min? It was concluded that the patient was recovering well, had taken the medication in accordance with the prescription, and was at low risk of complications. In that study, 150 (60%) out of 255 patients with PE were excluded from outpatient treatment using predefined criteria and another 57 (22%) were not treated due to admission at the weekend; only 16.8% were eventually managed as outpatients. A major strength of the present study is that it demonstrated that it is relatively straightforward to implement an ambulatory PE service where there are existing nurse-led DVT services with established local procedures for outpatient DVT treatment and, therefore, minimal cost implications. This is a very reasonable approach in practice-based conditions as well. 12 have published their experience of a further 108 subjects with PE treated as outpatients using the following exclusion criteria: 1) a medical condition that necessitated admission to hospital for another reason; 2) active bleeding or high risk of bleeding; 3) haemodynamic instability; 4) pain requiring parenteral narcotics; 5) requirement for oxygen therapy to maintain arterial oxygen saturation of >90%; 6) aged <18 yrs; and 7) likelihood of poor compliance. The attending physician considered the presence of acute PE. When establishing a PE outpatient pathway, 2 major decisions must be made. Is thrombolysis or embolectomy necessary? Davies*, J. Wimperis#, E.S. Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index? This is a major limitation and should be considered in future studies attempting to stratify the risk associated with outpatient treatment of PE. 2019 May 23. The severity of the PE and risk of adverse outcomes should largely determine clinical decision making with regard to initial home treatment. However, some hospitals are cautiously exploring ED treatment and discharge for PE. Five (22%) of the 23 patients were discharged the same day from the intensive care unit … 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). 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. Clinical guidelines recommend early discharge of patients with low-risk pulmonary embolism (LRPE). Outpatient pathway for acute pulmonary embolism. A similar study by Beer et al. AU - Alagappan, Kumar. In addition, patients had to fulfill several pragmatic criteria to rule out other factors necessitating hospital admission (ie, being independent from oxygen therapy and having an established support system at home). This score uses clinical parameters in combination with age, male sex and risk factors, such as cardiorespiratory disease and cancer. Acute pulmonary embolism (PE), the most severe presentation of venous thromboembolism (VTE), may be fatal if not diagnosed and treated in time.1 Because of the associated high mortality risk, hospitalization has been the standard of care for all PE patients for monitoring and initiation of anticoagulant therapy. In order to accelerate the patient pathway and optimise the benefits of savings in numbers of days in hospital, one of the present criteria for inclusion in phase 2 was that the diagnosis and subsequent discharge had to be made within 72 h of admission; thus the length of stay for phase 2 was influenced by this criterion. There were no significant complications or deaths during the acute treatment phase with LMWH, during which time patients had traditionally been kept in hospital. First of all, patients need to receive preferably written instructions on who and when to contact in case of alarm symptoms. Noninferiority was shown in the incidence of recurrent VTE (0.6% vs 0%) and non-PE related death (0.6% vs 0.6%) after a 3-month follow-up period for home treatment and hospitalization, respectively. All patients were treated with a vitamin K antagonist. In the Canadian studies 12, 14, support was provided with daily telephone contact by a research nurse, access to a 24-h telephone helpline and follow-up clinics at 1 week and 1 and 3 months. PY - 2017/12/1. Kovacs et al. Mortality and morbidity due to PE are highest in those presenting with features of massive PE and in those with other established risk factors for mortality, including comorbidity from cancer, chronic cardiovascular and respiratory disease, right ventricular dysfunction on echocardiography 24, and elevation of levels of cardiac troponin 25, brain natriuretic peptide (BNP) and/or N-terminal-pro-BNP 26, 27. The next step in managing patients with PE is to consider avoiding admission altogether in those predicted to be at low risk of adverse outcome. 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. 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). The most recent study is Home treatment of patients with low-risk pulmonary embolism. Several studies have shown the feasibility of treating patients with acute pulmonary embolism (PE) at home. Patients indicated a high level of satisfaction with their care.9. Eur Heart J. 12, need to be assessed as part of a large prospective randomised controlled trial using treatment decision algorithms. All-cause death occurred in 1.7% of patients in both groups (odds ratio, 1.0; 95% CI, 0.11-8.7).26 These observations suggest that the hemodynamic profile of a patient (ie, the severity of RV overload and the resulting hemodynamic response) rather than just an abnormal RV/LV ratio or NT-proBNP is intrinsically taken into account in the decision to treat patients at hospital or at home when applying the Hestia criteria. Online ISSN: 1399-3003, Copyright © 2021 by the European Respiratory Society. Pulmonary embolism home treatment: What GP want? None of the Hestia criteria were present, and home treatment was discussed with the patient. 12, some of the criteria used were relatively subjective, such as the need for admission for another medical condition, the need for additional monitoring or treatments and estimates of poor compliance. Phase 1 of the present study derived similar criteria for exclusion for safe outpatient PE management, which were used in phase 2. Of note, although the sPESI is much more user friendly than the PESI, well validated, and included in current guidelines, none of the landmark studies on home treatment of PE published to date applied this score.22-24 Even so, it may be assumed that PESI can be substituted with sPESI. Conflict-of interest disclosure: F.A.K. Early discharge of low-risk patients with pulmonary embolism has been suggested, but scarce data were available in everyday clinical practice. Yes, you read the question correctly… This was essentially the aim of a recent study published in Academic Emergency Medicine. Generally, home treatment is defined as a discharge within 24 hours of initial presentation and early discharge if patients leave the hospital within 3 days. Using outpatient anticoagulation therapy in these patients was safe and highly acceptable to patients, and can be implemented in a centre with existing deep venous thrombosis services. Although the exact answer to that question is subjective and may vary between individual physicians, patients, and policy makers, one thing is clear. • We showed that in daily clinical practice, given the presence of a dedicated outpatient pathway, about one third of PE patients can be safely managed by early discharge. They nonetheless provide important information for the outcomes of home-treated PE patients across a wide range of patient categories and countries. research staff and clinical nurse specialists) and if all patients are reviewed for potential early discharge. 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. 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. Her physical examination and electrocardiogram were unremarkable. On confirmation of the diagnosis of acute PE, oral anticoagulant therapy was initiated. Vasodilators: Vasodilators may improve blood flow by … Medical or social reason for treatment in the hospital for more than 24 h (infection, malignancy, no support system)? These symptoms may mean another blood clot. M.V.H. Get an overview of all published literature on home treatment of acute pulmonary embolism, Understand the evidence based risk stratification tools that can be used to select patients with acute PE for home treatment. CorrespondenceFrederikus A. Klok, Department of Medicine–Thrombosis and Hemostasis, Leiden University Medical Center, LUMC Room C7-14, Albinusdreef 2, 2300RC, Leiden, the Netherlands; e-mail: f.a.klok@lumc.nl. After 5 days in the Pneumology ward, weaning of HFNC was possible, maintaining good oxygen saturation values and hospital discharge was decided. Patients randomized to home treatment left the hospital of a mean of 0.5 days, whereas patients randomized to hospitalization were discharged after a mean of 3.9 days. A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. Home care. 14 treated 34 patients with PE and assessed both homecare nursing and patient administration of dalteparin (an LMWH), and found them acceptable and safe with few complications of therapy. Clinical guidelines recommend early discharge of patients with low-risk pulmonary embolism (LRPE). ED Discharge of Patients with Pulmonary Embolism; Marketing Rivaroxaban Do PE patients discharged from the ED on rivaroxaban have a shorter length stay than those admitted to hospital? As with the study by Kovacs et al. The median length of hospitalization was 34 hours, and … The study will compare the safety and efficacy of both strategies, with the hypothesis that both study groups treated at home because of either none of the Hestia criteria or a low-risk classification by sPESI will have comparable rates of adverse events but that decision making based on the Hestia criteria leads to more patients selected for home treatment. For the matter of RV overload, in the Hestia and VESTA studies, RV function evaluation (which is critical to the risk stratification as recommended by the European Society of Cardiology) was not part of standard baseline assessment. 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. Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). But you can take steps to prevent another pulmonary embolism by following your doctor's instructions. Mostly, however, the health care costs are much lower if (unnecessary) admission is prevented. Phase 1 suggested that this approach may lead to early discharge of 47% of subjects with PE, although the proportion suitable for immediate discharge may indeed be smaller if the diagnosis is confirmed more rapidly, as some patients may not be clinically stable on presentation. Hence, more than strictly adhering to rigid imaging or biomarker thresholds or only focusing on overall mortality, precision medicine is key, tailoring the optimal approach to the individual patient. In both phases of the present study, it was ensured that patients had a confirmed PE before being selected for early discharge. Fifty-eight percent of the PE patients screened for study participation were eligible for home treatment, and 51% were treated at home. A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. Patients with pulmonary embolism can be divided in two groups according to their risk of death or major complication: a small group of high‐risk patients defined by the presence of systemic hypotension or cardiogenic shock and a large group of normotensive patients. Early discharge of patients with pulmonary embolism: a two-phase observational study C.W.H. Severe pain needing intravenous pain medication for more than 24 h? In spreading the word on European Respiratory Society the apprehension of medical concerning... 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