There are almost 1,000,000 pulmonary embolisms per year. Do all of them need to be admitted? From a dispo standpoint, it can be easier when you’re at larger academic centers to admit or obs them all but the reality is that some of them can be discharged!
First off, this is attending-dependent. The idea of discharging PE’s started in the 2000’s. Currently, the majority of PEs are admitted. When considering discharge, there is a lot to keep in mind so let’s go through it. After reviewing literature on this, I’m going with Stratify, Select, and Connect.
- Stratify (risk stratify for bleeding and clot)
- Select (the anticoagulation)
- Connect (connect the patient to close follow-up and connect them to resources/education on PEs)
Stratify
The gold standard for identifying a PE is a CTA. Some risk stratification tools are the PE Severity Index (PESI), the simplified PESI (sPESI), and the Hestia criteria. The PESI and sPESI estimate 30-day mortality whereas the Hestia criteria is specifically to assess if a patient with a PE can be treated as outpatient. Therefore, if any of the Hestia criteria are met, the patient cannot be discharged. (Want to go in the weeds a bit? If so: there is also a modified Hestia criteria + POMPE-C criteria that has some good support. However, there’s not as much literature & the 2021 ACEP guidelines still rely on the Hestia criteria so we’ll stick to the Hestia). Okay, we’re back, you clicked through the Hestia criteria and there are no contraindications and MDCalc said you can discharge. WRONG. Use clinical decision tools to aid when applicable but there is way more to consider. This is a patient with a blood clot that you want to send home, consider aspects that may complicate medication compliance & follow up. For example: homelessness, dysregulated psychiatric disease, & social determinants of health that are barriers to care (the ones we deal with frequently). The other risk stratification is regarding bleeding. If the patient is at high risk for bleeding, they do not qualify for discharge. Contraindications include critical organ bleeding, recent surgery, trauma, stroke, malignancy, or thrombocytopenia. There are validated tools out there like the VTEBleed score but they look at long-term risk and studies don’t love using it to assess ED discharge. Discharge or not, the patient will be anticoagulated so you weigh the risks of anticoagulation for every PE patient anyway.
Select
Start them on a DOAC if you can. Compared to warfarin, they are faster, have fewer drug and food interactions, and have a fixed dose. You probably see a patient on a DOAC almost every shift, they are common! For a medication that is frequently used, we should feel comfortable with them. Here’s a great 5 minute video refresher! Apixaban (Eliquis) & rivaroxaban (Xarelto) don’t need parental anticoagulation with LMWH or fondaparinux (whereas Dabigatran & Edoxaban do), so use Eliquis or Xarelto. You can’t start a DOAC on a patient with severe renal impairment or in patients with BMI >40 readily from the ED so these patients should stay. However, if not, you’ve selected your anticoagulation!
So far, you’ve diagnosed the PE, and thought about if they are a reasonable discharge based on the Hestia criteria, clinical gestalt, and social/life factors. You’ve also decided they are safe to take Eliquis or Xarelto and have discussed this with them. Wow, you’re doing great. What else do you need to discuss with them?
Connect
They need to have PCP follow-up in 3-5 days. They should also be able to make it to their appointment, pay for the medication, and not get lost to follow up. They need strict return precautions & education about the DOAC you just started them on and the PE you just diagnosed them with. They need to know about the risk of bleeding, signs and symptoms of a worsening PE, and a detailed follow-up plan. We say ‘PCP follow-up’ frequently and move on. Why does this patient specifically need PCP follow-up? They may need dosage changes, they need someone to go over their risks and bleeding signs/symptoms again, & to ensure proper compliance.
You did it! You finished this email and, in our theoretical scenario, you discharged a patient with a PE. There is great literature on improved patient satisfaction, there are clinical trials showing this is safe, and there are more studies showing the benefit & safety of this method. There is even a 2023 ACEP Point of Care decision tool to aid you in this. Hopefully, you will consider this the next time you diagnose a PE!
Yours in learning,
Shivam
