Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.
Study design: Controlled pragmatic trial.
Setting: Kaiser Permanente Northern California (KPNC).
Synopsis: A total of 21 KPNC EDs participated in this 16-month study of 1,703 patients; 11 EDs served as control sites and 10 as intervention sites. At month 9, ED physician study champions at intervention sites provided in-person training on outpatient PE management, the validated PE severity index (PESI), and the electronic CDSS. The CDSS was designed to use evidence-based guidelines to assist physicians in identifying patients eligible for outpatient care or short-term (less than 24-hour) observation in the ED. The CDSS was incorporated into the electronic medical record navigator used by ED physicians and not only calculated the PESI score, but also provided the patient’s risk class and 30-day all-cause mortality estimate. Adverse outcomes were defined as 5-day return visits for PE-related symptoms, recurrent VTE, major hemorrhage, and all-cause 30-day mortality. Results demonstrated an increase in home discharge at intervention sites (17.4% pre to 28% post) without an increase in adverse outcomes.
Bottom line: Use of an electronic CDSS to identify patients appropriate for home management of acute PE decreased admission rates without increasing adverse outcomes.
Citation: Vinson DR et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Int Med. 2018;169(12):855-65.
Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.