Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out

Answers to the July 2018 Journal Club Questions
      Vinson et al
      • Vinson D.R.
      • Ballard D.W.
      • Huang J.
      • et al.
      Outpatient management of emergency department patients with acute pulmonary embolism: variation, patient characteristics, and outcomes.
      performed this retrospective cohort study examining the outpatient management of patients with acute pulmonary embolism at 21 community emergency departments (EDs) in Northern California between January 2013 and April 2015. The study found that 7.5% of patients were discharged.
      • A.
        The authors found that more than a third of hospitalized patients had Pulmonary Embolism Severity Index classifications I or II, who are considered low risk and candidates for outpatient management. Why did the authors think these “low-risk” patients were hospitalized? What was the 30-day adverse event rate in these patients? According to your own clinical experience, why might patients classified as low risk by clinical decision rules be admitted?
      • B.
        This study was conducted in January 2013 to April 2015 while most patients discharged were still being treated with low-molecular-weight heparin and warfarin. Do you think the results would be different if the study were to be repeated now with the increased availability of direct oral anticoagulants to treat pulmonary embolism?
      • C.
        This study was conducted at 21 community EDs in Northern California. Do you think that academic medical centers would have similar results? Might other factors about the study hospitals (eg, Northern California region, Kaiser Healthcare system) have affected the results compared with other EDs across the United States?
      • D.
        Greater than 90% of patients discharged home received follow-up with the hospital’s anticoagulation service within 3 days and with their primary care provider within a week. The authors acknowledge that timely follow-up may not be possible at other facilities. How might the availability, or lack thereof, of primary care or specialty follow-up at your institution affect ED clinicians’ acceptance of an outpatient management pathway for pulmonary embolism? Is follow-up within a week still needed for patients treated with one of the new direct oral anticoagulants?
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