2017 Dec;10(1):19. doi: 10.1186/s12245-017-0144-9. Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. 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). 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. The 90-day composite outcome of all-cause mortality, recurrent symptomatic VTE, and major bleeding occurred in 0.5 of patients (95% CI, 0.02-2.4). 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. But you can take steps to prevent another pulmonary embolism by following your doctor's instructions. Does the patient have a creatinine clearance of < 30 mL/min? In the last decade, several landmark studies have been published, demonstrating the safety of home treatment in selected low-risk PE patients. 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). 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. Frederikus A. Klok, Menno V. Huisman; When I treat a patient with acute pulmonary embolism at home. 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. Potential VTE-related medical resource use during follow-up was the same between groups.5. 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 … Mostly, patients are saved a hospital admission, which may lead to less anxiety, better quality of life, and higher patient satisfaction. 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. Is thrombolysis or embolectomy necessary? 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. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Hence, in our practice, we use the Hestia criteria without further explicit (imaging) biomarkers. This study measured the overall impact of early discharge of LRPE patients on clinical outcomes and costs in the Veterans Health Administration population. 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. Phase 1 of the present study derived similar criteria for exclusion for safe outpatient PE management, which were used in phase 2. 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. 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%. We report two cases of COVID-19 patients developing acute pulmonary embolism (PE) after discharge from a first hospitalization for pneumonia of moderate severity. Second, in most studies, patients were contacted by telephone or evaluated in an outpatient clinic in the first week after diagnosis. Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. 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. This concern is similar to that seen during the development of outpatient DVT management during the late 1990s, and may have influenced the ability to enter all suitable patients with PE into the present study. 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). Discharge Instructions for Pulmonary Embolism. Epub 2017 Jun 6. 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. Kovacs et al. PY - 2017/12/1. Early discharge of low-risk patients with pulmonary embolism has been suggested, but scarce data were available in everyday clinical practice. In both phases of the present study, it was ensured that patients had a confirmed PE before being selected for early discharge. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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. You may urinate more often when you take this medicine. On confirmation of the diagnosis of acute PE, oral anticoagulant therapy was initiated. Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. On triage, the patient was hypoxic and tachycardic, prompting a high index of suspicion for pulmonary embolism. • 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. 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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