SGEM#323: Mama I’m Comin’ Home – For Outpatient Treatment of a Pulmonary Embolism

Date: March 16th, 2021 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Reference: Westafer et al. Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism. AEM March 2021 Case: You are evaluating a 48-year-old female for pleuritic chest pain. She is low risk by Wells Criteria but PERC Rule positive because of an appendectomy last month. Her d-dimer comes back elevated, so you order a CT-PA to evaluate for pulmonary embolism (PE). The radiologist notes a distal sub-segmental PE on the right. The patient has normal vital signs and no comorbidities. Background: Historically most patients with PEs have been admitted to the hospital in the USA. This is in contrast to Canada where papers in the early 2000 demonstrated the safety of out-patient management of PEs (Kovacs). A study from 2010 showed that half of PE patient from one centre in Ontario were safely being treated as outpatients (Kovacs). Dr. Jeff Kline PE guru, creator of the PERC Rule and Editor-in-Chief of Academic Emergency Medicine, Dr. Jeff Kline, was senior author on a paper that looked at treating VTE with outpatient management using a DOAC (Bean et al AEM 2015). This relatively small study (n=106) reported successfully treating 51% of DVT patients and 27% of PE patients with rivaroxaban (SGEM#126). Literature from the USA reports that 90% of patients diagnosed with PE are admitted (Singer et al 2016). Another study showed less than 10% of PE patients are discharged home from the ED for out-patient therapy (Vinson et al 2017). A couple of international guidelines support the outpatient treatment of ED patients with low-risk PE. This includes the European Cardiology Society (ECS 2019) and the British Thoracic Society (Howard et al 2018). The American College of Emergency Physicians (ACEP) has a clinical policy that addresses this issue (Wolf et al 2018). The ACEP policy give outpatient management of PE patients a Level C recommendation: “Selected patients with acute PE who are at low risk for adverse outcomes as determined by PESI, simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the ED on anticoagulation, with close outpatient follow-up.” PESI (Pulmonary Embolism Severity Index) is a risk stratification tool based upon studies by Donzé et al 2008 and Choi et al 2009.  The PESI consists of eleven criteria with a different number of points awarded for each variable. This can be complicated and there is an online calculator to help (MDCalc PESI Score). The PESI score has been made even easier to use with the creation of the Simplified PESI. It only has six criteria, each has only one point and can also be computed online using MDCalc sPESI. The Hestia Criteria is another scoring system to identify low risk PE patients that could be considered for outpatient PE treatment. Like the PESI score it has eleven criteria and an online calculator (MDCalc Hestia Criteria). If all eleven criteria are negative the patient is low risk with a predicted mortality of 0% and VTE recurrence of 2%. However, if any one of the criteria is positive the patient is not low risk. These patients are not considered eligible for outpatient management based on this score and it is recommended they be admitted for inpatient therapy. Clinical Question: What are the current disposition practices, and outcomes, for patients with PE in US hospitals? Reference: Westafer et al. Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism. AEM March 2021 Population: Patients 18 years of age or older between July 2016 and June 2018 presenting to one of 740 acute care hospitals and receiving a diagnosis of PE based upon ICD-10 codes Exclusion: Patients diagnosed with PE in the previous 90 days, and those patients who expired during the ED visit