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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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      References

        • 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.
        Ann Emerg Med. 2018; 72: 62-72.e3
        • Gilbert E.H.
        • Lowenstein S.R.
        • Koziol-McLain J.
        • et al.
        Chart reviews in emergency medicine research: where are the methods?.
        Ann Emerg Med. 1996; 27: 305-308
        • Kaji A.H.
        • Schriger D.
        • Green S.
        Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies.
        Ann Emerg Med. 2014; 64: 292-298
        • Gouin B.
        • Blondon M.
        • Jimenez D.
        • et al.
        Clinical prognosis of nonmassive central and noncentral pulmonary embolism.
        Chest. 2017; 151: 829-837
        • Kahn S.R.
        • Houweling A.H.
        • Granton J.
        • et al.
        Long term outcomes after pulmonary embolism: current knowledge and future research.
        Blood Coagul Fibrinolysis. 2014; 25: 407-415
        • Pollack C.V.
        • Schreiber D.
        • Goldhaber S.Z.
        • et al.
        Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry).
        J Am Coll Cardiol. 2011; 57: 700-706
        • Fang M.C.
        • Fan D.
        • Sung S.H.
        • et al.
        Outcomes in adults with acute pulmonary embolism who are discharged from emergency departments: the Cardiovascular Research Network Venous Thromboembolism study.
        JAMA Intern Med. 2015; 175: 1060-1062
        • Stein P.D.
        • Matta F.
        • Hughes P.G.
        • et al.
        Home treatment of pulmonary embolism in the era of novel oral anticoagulants.
        Am J Med. 2016; 129: 974-977
        • Barrett T.W.
        • Wrenn K.D.
        • Slovis C.M.
        • et al.
        An outpatient management protocol for emergency department patients with a newly diagnosed lower extremity deep venous thrombosis.
        Crit Pathw Cardiol. 2016; 15: 75-76
        • Kearon C.
        • Akl E.A.
        • Ornelas J.
        • et al.
        Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.
        Chest. 2016; 149: 315-352
        • Howard L.S.G.E.
        • Barden S.
        • Condliffe R.
        • et al.
        British Thoracic Society guideline for the initial outpatient management of pulmonary embolism (PE).
        Thorax. 2018; 73: ii1-ii29
        • Wolf S.J.
        • Hahn S.A.
        • Nentwich L.M.
        • et al.
        Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease.
        Ann Emerg Med. 2018; 71: e59-e109
        • Erkens P.M.
        • Gandara E.
        • Wells P.
        • et al.
        Safety of outpatient treatment in acute pulmonary embolism.
        J Thromb Haemost. 2010; 8: 2412-2417
        • Vinson D.R.
        • Ballard D.W.
        • Huang J.
        • et al.
        • Kaiser Permanente CREST Network
        Timing of discharge follow-up for acute pulmonary embolism: retrospective cohort study.
        West J Emerg Med. 2015; 16: 55-61
        • Barrett T.W.
        • Schriger D.L.
        Measures of emergency department crowding, odds ratios, and the dangers of making continuous data categorical: answers to January 2008 Journal Club questions.
        Ann Emerg Med. 2008; 51: 782-789
        • Barrett T.W.
        • Schriger D.L.
        Full of hot air? do patients with large spontaneous pneumothoraces require hospitalization? answers to the September 2014 Journal Club questions.
        Ann Emerg Med. 2015; 65: 224-230
        • Aujesky D.
        • Obrosky D.S.
        • Stone R.A.
        • et al.
        Derivation and validation of a prognostic model for pulmonary embolism.
        Am J Respir Crit Care Med. 2005; 172: 1041-1046
        • Zondag W.
        • den Exter P.L.
        • Crobach M.J.
        • et al.
        • on behalf of the HESTIA Study Investigators
        Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolism.
        Thromb Haemost. 2013; 109: 47-52
        • Maestre A.
        • Trujillo-Santos J.
        • Riera-Mestre A.
        • et al.
        Identification of low risk patients with acute symptomatic pulmonary embolism for outpatient therapy.
        Ann Am Thorac Soc. 2015; 12: 1122-1129
        • Kabrhel C.
        • Rosovsky R.
        • Baugh C.
        • et al.
        The creation and implementation of an outpatient pulmonary embolism treatment protocol.
        Hosp Pract (1995). 2017; 45: 123-129
        • Becattini C.
        • Cohen A.T.
        • Agnelli G.
        • et al.
        Risk stratification of patients with acute symptomatic pulmonary embolism based on presence or absence of lower extremity DVT: systematic review and meta-analysis.
        Chest. 2016; 149: 192-200
        • Jiménez D.
        • Aujesky D.
        • Díaz G.
        • et al.
        RIETE Investigators. Prognostic significance of deep vein thrombosis in patients presenting with acute symptomatic pulmonary embolism.
        Am J Respir Crit Care Med. 2010; 181: 983-991
        • Tzoran I.
        • Saharov G.
        • Brenner B.
        • et al.
        RIETE Investigators. Silent pulmonary embolism in patients with proximal deep vein thrombosis in the lower limbs.
        J Thromb Haemost. 2012; 10: 564-571