Low Risk Acute PE? send 'Em Home!

Treating well selected patients with VTE at home without admission is something our group has discussed on and off for the last several years. Today we have a special guest on the show one of our intensivists Jermaine Jackson, MD.

2016 ACCP Guidelines :

"In patients with low risk PE and whose home circumstances are adequate, suggest treatment at home or early discharge over standard discharge (e.g., after the first 5 days of treatment"

2012 ACCP Guidelines :

Standard 5 day admission for PE’s with the caveat that some could be discharged early at 2 days in “low risk PE patients.

British Thoracic Society 2003 Guidelines

Suggested that outpatient treatment of pulmonary embolism can be considered under 3 specific scenarios: 1. The patient is not unduly breathless. 2. There are no medical or social contraindications and 3. There is an efficient protocol in place.

sPESI (simiplified Pulmonary Embolism Severity Index)

The components include

  1. Age > 80­­­­­­­
  2. History of cancer
  3. Chronic cardiopulmonary disease
  4. Pulse > 110
  5. SBP < 100
  6. SpO2 < 90% (requiring oxygen)

Low risk of death is a score of 0.

Home Treatment of Pulmonary Embolism in the Era of Novel Oral Anticoagulants

  • 983 patients seen in the ED with Acute PE
    • 237 ineligible for home treatment
    • 746 total eligible
      • Only 13 actually discharge home!
      • 119 discharged in < 2 days
      • 651 were kept longer than 2 days!
  • Why did this occur?
    • too many scoring models?
    • people haven't adapted their practice to current guidelines and evidence based practice?

Jermaine Jackson makes some great points about subsegmental PEs :

  • Do they happen more frequently than we know?
  • Should we be treating them at all?
  • What are the barriers to not treating them?

Hospital Costs of acute PE

  • mean total hospitalization cost for treating a patient with PE was $8764
  • Room and Board with nursing costs was the largest expense at $5102
  • Total hospital expenditure over a 6.5 year period was 8.6 million (prices started in 2003 so assume higher now)

Closing Discussion

  • Should we be calculating sPESI scores on all patients with PE?
  • Should we be sending patients home with PE?
  • Are there any barriers to doing this? Case management?
  • Will insurance companies stop paying for admissions for low risk PE?

We want to hear from you!

Are you already doing this at your shop?

Which scoring model do you use?

Is it build into your EMR?

Do you have your process streamlined with case management?