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. The RCT (Aujesky 2011) used Pulmonary Embolism Severity Index (PESI) in order to qualify for study; In some Canadian centers, the discharge rate for PE is 51%; in a sample of 22 US EDs (1880 patients), it was only 1.1%. Hence, in our practice, we use the Hestia criteria without further explicit (imaging) biomarkers. The attending physician considered the presence of acute PE. 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). A similar study by Beer et al. 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. A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. The Pulmonary Embolism Severity Index (PESI) predicts 30-day outcome of patients with pulmonary embolism using 11 clinical criteria. 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. Discharge Instructions for Pulmonary Embolism . Five (22%) of the 23 patients were discharged the same day from the intensive care unit … Diagnostic and Prognostic Models in VTE Management: Ready for Prime time? All patients were treated with a vitamin K antagonist. These are especially important if you were discharged home from the emergency department. 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. 2019 May 23. Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. A pulmonary embolism (PE) is the sudden blockage of a blood vessel in the lungs by an embolus. The Hestia study evaluated the efficacy and safety of home treatment in 297 PE patients using the Hestia criteria to identify eligibility for home treatment.6  The Hestia criteria are pragmatic criteria of both risk of mortality and bleeding but also of other reasons for hospitalizing patients with acute PE such as hypoxemia, pain requiring analgesia, and bleeding risk (Table 2). 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. AU - Alagappan, Kumar. Overview of the diagnosis of pulmonary embolism. The first one concerns the selection of patients for home treatment. She lived together with her husband who could take care of her, and she responded favorable to the suggestion of home treatment. This is a pulmonary embolism (PE). Only one small series 30 has addressed this area. 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. In the past decade, however, studies have shown that PE patients can be stratified into classes of higher or lower risk of adverse outcome based on clinical decision rules, biomarkers, and/or assessment of right ventricular (RV) function.2  Guidelines now recommend formal risk stratification to guide the optimal therapeutic management, and it has been suggested that this may have led to a decrease in PE-related mortality.3,4  This risk stratification cannot only be used to identity patients that benefit from reperfusion therapy but also to select patients who can be managed at home. 12 showed a much higher incidence of complications than the present study, which may reflect different patient selection despite the similar exclusion criteria, and could be due to interobserver variability in the application of these criteria. But you can take steps to prevent another pulmonary embolism by following your doctor's instructions. 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. Pulmonary embolism is very serious and may cause death if the clot is large or there are multiple clots. Fifty-eight percent of the PE patients screened for study participation were eligible for home treatment, and 51% were treated at home. PY - 2017/12/1. The first one concerns the selection of patients for home treatment. As with the study by Kovacs et al. I f a patient shows up in the emergency department with a pulmonary embolism (PE), is it safe to send him home? Enter multiple addresses on separate lines or separate them with commas. Conclusion: The discharge of low-risk patients is feasible & safe Echocardiography and biochemical predictive tests were not performed routinely as part of the present study since neither was routinely available in the study centres at the time the study commenced. Six days after immediate discharge from the emergency department, she visited our dedicated thrombosis outpatient clinic. M.V.H. Early discharge of patients with pulmonary embolism: a two-phase observational study C.W.H. Vasodilators: Vasodilators may improve blood flow by … Because PESI with/without measures of RV overload focuses on risk of early adverse alone and not on assessing the possibility of home treatment, PESI should always be combined with other Hestia-like criteria for this purpose as was done in the Outpatient Treatment of Pulmonary Embolism study.5, If patients are treated at home, a proper outpatient pathway should be in place (Figure 1). For instance, practice-based studies have shown that 45% to 55% of hemodynamically stable PE patients are treated at home in Canada and the Netherlands, whereas in Spain and France, most patients are hospitalized.13,16-20  The introduction of direct oral anticoagulants with a superior safety profile compared with vitamin K antagonists and many practical advantages have lowered the bar for home treatment of PE.13,21  However, home treatment of PE has not (yet) become the standard of care in 2020. Conflict-of interest disclosure: F.A.K. The variety of centres that participated, involving both district general and regional teaching hospitals, also implies that this approach is widely applicable and not restricted to specialist centres. 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. Early discharge of low-risk patients with pulmonary embolism has been suggested, but scarce data were available in everyday clinical practice. Discharge Instructions for Pulmonary Embolism . A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. 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. The severity of the PE and risk of adverse outcomes should largely determine clinical decision making with regard to initial home treatment. Does the patient have a creatinine clearance of < 30 mL/min? According to the literature discussed above, 2 triaging tools have been found adequate for selecting PE patients for home treatment: the Hestia criteria and PESI, with or without biomarker assessment or evaluation of the presence of RV overload. 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). Rivaroxaban was given at the approved dose for treatment of venous thromboembolism (VTE)/PE for at least 3 months. Keely MA. 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. 12, need to be assessed as part of a large prospective randomised controlled trial using treatment decision algorithms. There were no adverse events relating to treatment or complications while at home overnight. 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. 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. © 2020 by The American Society of Hematology. Her physical examination and electrocardiogram were unremarkable. When establishing a PE outpatient pathway, 2 major decisions must be made. Their presentation, hospital courses, complications, and follow-up are reviewed. Because of this, major regional differences can be observed. Case summary Two patients with positive RT-PCR test were initially hospitalized for non-severe COVID-19. More patients with pulmonary embolism or deep vein thrombosis were discharged on rivaroxaban after the protocol roll-out than before (58.9% vs 24.2%; P < .001). N2 - Background: … 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 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. A PE can become life-threatening. 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. It is likely that the patients with the highest scores (higher risk of 30-day mortality) would also be selected out by the criteria used in the present phase 2 exclusion, simply because they are more likely to require admission for additional treatment or monitoring and would be acutely unwell. Emergency department management of incidental pulmonary embolism in patients with cancer. 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. This is a very reasonable approach in practice-based conditions as well. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Recruitment is likely to be easier with dedicated specialised staff (e.g. • 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. 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. If the answer to one of the questions is yes, the patient cannot be treated at home in the Hestia 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. More than 24 h of oxygen supply to maintain oxygen saturation > 90%? Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard. 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. Of those, 13 met 1 of the imaging exclusion criteria. Noninferiority was shown for the composite outcome of PE- or bleeding-related mortality, cardiopulmonary resuscitation and intensive care unit admission, which occurred in 1.1% (95% CI, 0.2-3.2) and 0% (95% CI, 0-1.3), respectively. Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. However, the scores predicting 30-day and 3-month mortality are not likely to be clinically useful when trying to predict the safety of outpatient treatment during the acute phase with LMWH, the treatment phase currently performed as an in-patient. As a consequence, 30% of all patients treated at home had a RV/left ventricular (LV) diameter ratio > 1.0, without a higher incidence of adverse outcome: the combined 3-month incidence of recurrent VTE and all-cause death was 2.7% in patients treated at home with a RV/LV diameter ratio > 1.0 and 2.3% in patients with a normal RV/LV ratio.25  Furthermore, high sensitive troponin-T (hsTnT) did not have an additional prognostic value on top of Hestia, as was the case for NT-proBNP in the VESTA study.7,26  The adverse 30-day composite outcome of hemodynamic instability, intensive care unit admission, or death related to either PE or major bleeding occurred in 1.7% patients treated at home with post hoc measured elevated hsTnT levels compared with 0.70% with normal hsTnT (odds ratio, 2.5; 95% CI, 0.22-28). In both phases of the present study, it was ensured that patients had a confirmed PE before being selected for early discharge. 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. Frederikus A. Klok, Menno V. Huisman; When I treat a patient with acute pulmonary embolism at home. research staff and clinical nurse specialists) and if all patients are reviewed for potential early discharge. 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. After 5 days in the Pneumology ward, weaning of HFNC was possible, maintaining good oxygen saturation values and hospital discharge was decided. 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. The trial protocol mandated that patients be discharged from the hospital within 48 hours of initial presentation for PE; it tolerated up to two nights of hospital stay. 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. 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. DISCHARGE INSTRUCTIONS: Medicines: Diuretics: This medicine is given to remove excess fluid from around your lungs and decrease your blood pressure. 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. Pulmonary embolism can be very serious. 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. Symptoms had started 1 week before presentation. A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. 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. The attending physician now must decide on the optimal setting of treating this patient: does she require hospitalization or is she a candidate for home treatment? 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. The patient remained clinically stable during the following days, allowing a progressive reduction of the flow. Recurrent VTE is also a risk factor for mortality, ≤26% in one case series 29, and so patients developing recurrent PE were excluded from the present study in order to ensure that only the safest patients were considered for outpatient treatment. T2 - a retrospective study. In this study 30, 50 highly selected patients with suspected PE attending an emergency department in Canada received one dose of dalteparin and were then discharged overnight, with further investigations arranged as an outpatient. The patient was hemodynamically stable and required no other treatment than (oral) anticoagulation. This editorial refers to ‘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’ †, by S. Barco et al., on page 509. 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. 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. AU - Rice, Terry W. AU - Reyes-Gibby, Cielito C. AU - Wu, Carol C. AU - Todd, Knox H. AU - Peacock, W. Frank . 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. Severe pain needing intravenous pain medication for more than 24 h? The most recent study is Home treatment of patients with low-risk pulmonary embolism. Cambron JC, Saba ES, McBane RD, et al; Adverse Events and Mortality in Anticoagulated Patients with Different Categories of Pulmonary Embolism. Medical or social reason for treatment in the hospital for more than 24 h (infection, malignancy, no support system)? Outpatient treatment after early discharge was highly acceptable to patients, and use of once-daily tinzaparin required no significant laboratory monitoring. 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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