All 5 patients … Using outpatient anticoagulation therapy in these patients was safe and highly acceptable to patients, and can be implemented in a centre with existing deep venous thrombosis services. Copyright ©2020 by American Society of Hematology. After 5 days in the Pneumology ward, weaning of HFNC was possible, maintaining good oxygen saturation values and hospital discharge was decided. Does the patient have a creatinine clearance of < 30 mL/min? Recurrent VTE is also a risk factor for mortality, ≤26% in one case series 29, and so patients developing recurrent PE were excluded from the present study in order to ensure that only the safest patients were considered for outpatient treatment. 2 In a U.S. National Hospital Ambulatory Medical Care Survey analysis, during 2006 to 2010, >90% of ED patients diagnosed with pulmonary embolism (PE) were hospitalized. Outpatient treatment after early discharge was highly acceptable to patients, and use of once-daily tinzaparin required no significant laboratory monitoring. Second, in most studies, patients were contacted by telephone or evaluated in an outpatient clinic in the first week after diagnosis. 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. In the last decade, several landmark studies have been published, demonstrating the safety of home treatment in selected low-risk PE patients. Both received standard thromboprophylaxis during the index hospitalization and had no strong predisposing risk … Thank you for your interest in spreading the word on European Respiratory Society . The VESTA study was a noninferiority trial in which 550 patients with acute PE and none of the Hestia criteria were randomized between immediate home treatment and advanced risk stratification via n-terminal pro-brain natriuretic peptide testing. 12, need to be assessed as part of a large prospective randomised controlled trial using treatment decision algorithms. 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. It is likely that the patients with the highest scores (higher risk of 30-day mortality) would also be selected out by the criteria used in the present phase 2 exclusion, simply because they are more likely to require admission for additional treatment or monitoring and would be acutely unwell. The protocol in many hospitals says absolutely not: The vast majority of PE patients are routinely admitted for several days to monitor their condition and supervise the start of anticoagulants. T1 - Discharge or admit? Such patients may even prefer being at home surrounded by relatives over hospital admission. As a significant proportion of patients with DVT also have silent PE (as defined by high-probability V’/Q’ scans) 3–6, it is likely that many patients who receive outpatient treatment for DVT have also received outpatient treatment of PE. The most recent study is Home treatment of patients with low-risk pulmonary embolism.10 In total, 525 of 2854 screened patients with acute PE were treated with rivaroxaban and discharged early in the absence of any of the Hestia criteria, signs of RV dysfunction or free-floating thrombi in the right atrium or RV, and contraindications to rivaroxaban. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. The patient was hemodynamically stable and required no other treatment than (oral) anticoagulation. At that moment, it is important to check the vital parameters, as well as whether the patient is doing well, follows the anticoagulant drug prescription, is aware of alarm symptoms, has received sufficient patient education, and has no untreated modifiable risk factors for complications such as major bleeding.27-29 If the patient is recovering according to expectation and if no other interventions are necessary, the routine patient pathway can be followed, with additional visits to establish the optimal duration of anticoagulation and, if indicated, tests to rule out underlying disease. Mostly, however, the health care costs are much lower if (unnecessary) admission is prevented. Results from ongoing trials are expected to enforce current guideline recommendations on home treatment and pave the way for more broad application of this elegant and cost effective management option for patients with acute PE. The study will compare the safety and efficacy of both strategies, with the hypothesis that both study groups treated at home because of either none of the Hestia criteria or a low-risk classification by sPESI will have comparable rates of adverse events but that decision making based on the Hestia criteria leads to more patients selected for home treatment. There were no adverse events relating to treatment or complications while at home overnight. Home treatment is feasible and safe in selected PE patients and is associated with a considerable reduction in health care costs. The severity of the PE and risk of adverse outcomes should largely determine clinical decision making with regard to initial home treatment. DISCHARGE INSTRUCTIONS: Medicines: Diuretics: This medicine is given to remove excess fluid from around your lungs and decrease your blood pressure. Get an overview of all published literature on home treatment of acute pulmonary embolism, Understand the evidence based risk stratification tools that can be used to select patients with acute PE for home treatment. More than 24 h of oxygen supply to maintain oxygen saturation > 90%? A major strength of the present study is that it demonstrated that it is relatively straightforward to implement an ambulatory PE service where there are existing nurse-led DVT services with established local procedures for outpatient DVT treatment and, therefore, minimal cost implications. Hematology Am Soc Hematol Educ Program 2020; 2020 (1): 190–194. Phase 1 of the present study derived similar criteria for exclusion for safe outpatient PE management, which were used in phase 2. A PE can become life-threatening. Acute death from hemodynamic deterioration or major bleeding in the first few days after diagnosis is a price too high to pay. Although the exact answer to that question is subjective and may vary between individual physicians, patients, and policy makers, one thing is clear. Previous smaller studies have also identified subgroups of PE patients who appeared to be suitable for safe outpatient management of PE. It was concluded that the patient was recovering well, had taken the medication in accordance with the prescription, and was at low risk of complications. Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Recruitment is likely to be easier with dedicated specialised staff (e.g. There are many benefits of treating patients with acute PE at home. https://doi.org/10.1182/hematology.2020000106. Conclusion: The discharge of low-risk patients is feasible & safe doi: https://doi.org/10.1182/hematology.2020000106. Six days after immediate discharge from the emergency department, she visited our dedicated thrombosis outpatient clinic. We do not capture any email address. Their presentation, hospital courses, complications, and follow-up are reviewed. Her physical examination and electrocardiogram were unremarkable. Keely MA. Eight weeks and 3 months later, she was evaluated by 1 of the thrombosis specialists of our department, who ruled out antiphospholipid syndrome, cancer, and chronic thromboembolic pulmonary hypertension and decided together with the patient to continue anticoagulant therapy indefinitely considering the absence of a clear provoking factor. Conflict-of interest disclosure: F.A.K. In both phases of the present study, it was ensured that patients had a confirmed PE before being selected for early discharge. Go to follow-up appointments and take blood thinners as directed. Discharge or admit? Eur Heart J. Mortality and morbidity due to PE are highest in those presenting with features of massive PE and in those with other established risk factors for mortality, including comorbidity from cancer, chronic cardiovascular and respiratory disease, right ventricular dysfunction on echocardiography 24, and elevation of levels of cardiac troponin 25, brain natriuretic peptide (BNP) and/or N-terminal-pro-BNP 26, 27. Derivation and validation of a prognostic model for pulmonary embolism. The Geneva score uses clinical parameters, such as history of cancer, heart failure or VTE, hypotension and hypoxaemia, but only looks at outcome after 3 months 31. 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). 10 In total, 525 of 2854 screened patients with acute PE were treated with rivaroxaban and discharged early in the absence of any of the Hestia criteria, signs of RV dysfunction or free-floating thrombi in the right atrium or RV, and contraindications to rivaroxaban. Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. The median length of hospitalization was 34 hours, and 12% of patients were discharged directly on confirmation of the PE diagnosis. Results from ongoing trials are expected to enforce current guideline recommendations on home treatment and pave the way for more broad application of this elegant and cost-effective management option for patients with acute PE. Separate from the vein, travel to the lungs and cut off blood flow by CT! And pleuritic chest pain both received standard thromboprophylaxis during the following days, allowing a progressive reduction the..., weaning of HFNC was possible, maintaining good oxygen saturation > 90 % should largely determine clinical decision with. Making with regard to initial home treatment, and she responded favorable the! Yes, you read the question correctly… this was essentially the aim of a vessel. 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