Low PESI Score with PE....to the hizzouse??

[Groove]

Just curious what practice patterns you guys are adopting based on the current lit regarding low risk PE's.

I'm noticing more and more studies utilizing risk stratification tools such as PESI to identify low risk PEs that can be discharged home on anti-coagulation but I honestly haven't really incorporated aggressive discharge of PEs into my practice quite yet though I'm meeting more and more ED docs who do. It usually involved medicine being consulted with a hospitalist insisting on discharging them on NOAC/DOAC (30d free card) and close f/u. When I trained, 100% PEs got admitted.

I knew the day was coming but I guess I just thought it would be 5 or 10 more years before it started to become mainstream standard of care. Honestly, I've been catching myself up with a current lit search on the subject and some of the studies look pretty good.

Are you guys sending many of these home from the ED? Are you using PESI? If not, how are you specifically risk stratifying them in the ED prior to discharge and what EBL are you using?

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[fahimaz7]

I discharge nearly all low-risk PE's on NOAC's. I can't think of the last time I admitted someone who was hemodynamically stable, negative trop/BNP, and a reasonable clot burden. This was the norm where I trained as well. 30 day mortality for a non-submassive or massive PE is exceedingly low.

I do use PESI in the documentation side of the equation.

 

[deleted109597]

If they don't get thrombolytics, they can probably go home.
I try and send them home. The little old ladies sometimes are a hard sell.

 

[RustedFox]

In Texas, Colorado, or Kansas.... yes.

In Florida, no.

The one item that needs to be discussed is how "smart" your PE patient is.
I don't trust anyone to follow their DCI. Especially here.

 

[DrDrummer]

Jeff Kline talked about this topic on EMRAP last month - it was a really good segment. He discussed the Hestia criteria, which I was not familiar with before that episode, and how he uses that in conjunction with biomarkers and taking into account elements about the patient's ability to comply / follow up with treatment to determine whether it is appropriate to do outpatient management. I'd recommend checking that out, or reading some of the overviews at REBEL:EM or the SGEM that cover the same material. There's not a lot extra to do for many of these patients in the hospital, and I think this is an area ripe for evidence-informed shared decision making.

 

[deleted109597]

In Texas, Colorado, or Kansas.... yes.

In Florida, no.

The one item that needs to be discussed is how "smart" your PE patient is.
I don't trust anyone to follow their DCI. Especially here.

Do they become smarter with their 2 midnight stay in the hospital, or are you simply playing hot potato?

 

[Groove]

I'm listening to that Jeff Kline "hestia study" podcast (Thanks for that Drummer, interesting...was familiar with PESI but not hestia) and just aspirated on my coffee when he said "I send saddle emboli home if their hestia and biomarkers are neg!" LOL, no thank you dude.

Man, I wish I worked in an academic center with sovereign immunity in a state like CO/TX. My cajones would be the size of grapefruits. I'd be doing ED appendectomies and discharging cerebral hemorrhagic contusions. I'd be a total rock star. Instead, I'm a community ED paranoid schizophrenic.

 

[turkeyjerky]

Do they become smarter with their 2 midnight stay in the hospital, or are you simply playing hot potato?

Hot potato...but seriously, if someone does 1 week after being discharged from the ED, it looks like you screwed up and missed something (or made the diagnosis and inappropriately discharged). If someone dies a week after they were hospitalized for 3 days it looks like an unfortunate event.

It's been about a year since I reviewed the literature on this tropic, but my takeaway then was that it seems completely appropriate to Schaefer low risk PE and that the outcomes are equivalent to hospitalization. However, there is an insignificant rate of death over the next two months (I recall around 2%, which doesn't differ between hospitalized and discharged patients), so that until the medical community and society recognize that has an appropriate death rate (which I personally do--we're frequently talking about old or medically comorbidities people, or people w/ undiagnosed cancer; i.e. People who die), then I'll continue to admit.

As far as the argument that 'we don't do anything for these patients in the hospitals that they can't do at home' goes...pfffft, I would estimate that 80-90% of my admissions are primarily for monitoring when you get down to it.

 

[WilcoWorld]

Do they become smarter with their 2 midnight stay in the hospital, or are you simply playing hot potato?

I was considering posting something about admitting people with a fall risk, as sending that patient home on anticoagulation is a risk for ICH. Then I thought, are they going to not be a fall risk when they're discharged in 2 days? Nope.

 

[WilcoWorld]

Hot potato...but seriously, if someone does 1 week after being discharged from the ED, it looks like you screwed up and missed something (or made the diagnosis and inappropriately discharged). If someone dies a week after they were hospitalized for 3 days it looks like an unfortunate event.

It's been about a year since I reviewed the literature on this tropic, but my takeaway then was that it seems completely appropriate to Schaefer low risk PE and that the outcomes are equivalent to hospitalization. However, there is an insignificant rate of death over the next two months (I recall around 2%, which doesn't differ between hospitalized and discharged patients), so that until the medical community and society recognize that has an appropriate death rate (which I personally do--we're frequently talking about old or medically comorbidities people, or people w/ undiagnosed cancer; i.e. People who die), then I'll continue to admit.

As far as the argument that 'we don't do anything for these patients in the hospitals that they can't do at home' goes...pfffft, I would estimate that 80-90% of my admissions are primarily for monitoring when you get down to it.

Great post. Also, can you please explain to me what it means when you use "Schafer" as a verb?

 

[xaelia]

We should definitely be sending home VTE – seems like about one-half to one-third meet the various low-risk stratifications of PE.

If you're not in TX/CO, I'd just suggest formalizing a departmental guideline aligned with something the national experts have written. A lot easier to defend practice and the random poor outcome that's been adopted as the "local standard of care", essentially.

 

[turkeyjerky]

Great post. Also, can you please explain to me what it means when you use "Schafer" as a verb?

Haha. AI at work

Xaelia, are there national guidelines recommending outpatient management of PE? Honestly asking.

 

[RustedFox]

Do they become smarter with their 2 midnight stay in the hospital, or are you simply playing hot potato?

They may not get smarter, but they get education that I can't provide/don't have the time to provide.

I diagnosed a PE last week in a guy who thought that when the xarelto ran out, that his DVT was "gone".

 

[deleted109597]

As far as the argument that 'we don't do anything for these patients in the hospitals that they can't do at home' goes...pfffft, I would estimate that 80-90% of my admissions are primarily for monitoring when you get down to it.

There are historical articles discussing when they went from something like 8 weeks of admission for observation after NSTEMI to something like 4 weeks. People though the sky was falling then as well. We can't monitor everyone, and if you are then the hospital is full and other things aren't getting done.
It's been proven safe to discharge many of these. It's also been proven safe to shock a fib back into sinus and discharge. One day we will get there.

 

[deleted245139]

They may not get smarter, but they get education that I can't provide/don't have the time to provide.

I diagnosed a PE last week in a guy who thought that when the xarelto ran out, that his DVT was "gone".

This is my issue with this...
Patient education and securing follow up. Years ago Annals had a paper on small PTX with a pigtail discharged home with close follow up and negligible complication rates... Sounds awesome in theory, but application is SO dependent on your patient population. I DO think we are over intervening on these small subsegmental PEs and if you can ensure follow up and the hypercoaguable workup in the right person, this may be an option, but alot rests on the individual patient

 

[RustedFox]

This is my issue with this...
Patient education and securing follow up. Years ago Annals had a paper on small PTX with a pigtail discharged home with close follow up and negligible complication rates... Sounds awesome in theory, but application is SO dependent on your patient population. I DO think we are over intervening on these small subsegmental PEs and if you can ensure follow up and the hypercoaguable workup in the right person, this may be an option, but alot rests on the individual patient

It's true.

My average patient is a 72 year old retiree who is already on enough brain-addling drugs to make life a blur. Either that, or they can't be bothered to write down their meds, let alone know why they take them, or the name of their PMD.

 

[justaregularmed]

If I'm going to discharge a DVT or PE the discharge has to be discussed with the/a PMD or no dice. Who's going to refill the xerdaxarin or follow up the etiological workup? Hopefully some teaching occurs as an inpatient as well.

 

[deleted109597]

My average patient is a 72 year old retiree who is already on enough brain-addling drugs to make life a blur. Either that, or they can't be bothered to write down their meds, let alone know why they take them, or the name of their PMD.

Again, do they live in a hospital 24/7? If so, then send them back there. If not, then your argument that it's suddenly too unsafe to add 1 more medicine to their already huge list is basically just shrugging. I mean, I get it, but at the same time, it's not like you're saving anything here by admitting them either.
And, as before, if your work environment sucks that hard, it's not like there aren't other jobs out there that suck differently.