A great conversation broke out the other day on Twitter, when it was asked by a US emergency physician if anyone sends home their low risk PE patients on LMWH. An international discussion ensued, with EP’s from Sweeden, the UK, and the US to name a few discussing how they manage PE.
Check out the initial conversation.
This discussion generated the links to a number of great references that support outpatient management of select patients with PE. Check them out at your own leisure from the above link.
This discussion has now been going on over the course of the weekend. Michelle Lin also posted a great Paucis Verbis card about the PESI, or Pulmonary Embolism Severity Index score. It is a great summary. This link also contains a discussion amongst other great minds in emergency medicine on Twitter about this very topic.
The resounding theme from US physicians: it seems most would like to/are willing to send low risk patients with PE home, but there is an overall fear of a bad outcome or litigation. As was pointed out in all these discussions, our medical culture is more lawyer heavy, and the constant fear of a lawsuit makes us hesitant to take such risks.
I agree wholeheartedly, however, with our international cohort. This is something that is being done safely in other countries. We regularly send home DVT patients on LMWH, something that was unheard of just years ago. How many of these DVT patients have small PE’s that we are not picking up and do just fine? Does it make financial sense to admit all of these people, some of whom go home in the first 48 hours anyway? Do these patients benefit from being exposed to iatrogenic complications when we could do the same thing with them at home?
Furthermore, and perhaps more importantly, I feel we are picking up far too many PE’s. How many people that we diagnose with small PE’s who have normal vital signs, minimal symptoms, and no residual DVT really benefit from our treatment, and how many do we harm with bleeding complications or medication reactions? We have become so gripped with fear of the bad outcome and the ensuing lawsuit that we have lost sight of the most important question: is what I am doing helping the patient, or hurting them?
My take on all of this is that there is a fair amount of evidence that in a subset of patients with PE who have normal vitals, normal labs, and no residual DVT, and who are overall low risk with few medical comorbidities, outpatient treatment with LMWH is safe and can be done effectively as others are doing it around the world. The PESI score is promising, but needs further external validation before you can apply it to our population as a whole. Everyone is going to have their N=1 of the low risk patient who went home with a DVT and came back with a PE on LMWH, but you have to ask yourself, would being in the hospital have prevented that? The answer is no.
In order to do this in the US, as our culture stands currently, a few things need to happen. First, discussions like the ones that have been going on are a great start. Great minds in EM need to come together and deem that this is a reasonable approach, and that it could be part of our standard of care. Second, further studies in the US need to push these boundaries and establish that this can be safely and effectively done. Third, institutional initiatives, both from hospitals and their health systems and representative bodies such as ACEP and AAEM, are needed to come up with criteria for outpatient treatment and standardization of care. I at this point would not send home one of these patients without that institutional support and agreement.
The American College of Chest Physicians has suggested that patients can be discharged “early” after the diagnosis of PE is made if they are stable, low risk, have good follow up, and can inject LMWH. Does this mean from the ED? I’d like to think so, and the webpage I referenced would suggest that. From my research, I cannot find any ACEP or AAEM guidelines that recommend discharge home from the ED in patients with PE.
My hope is that soon we will be sending these patients home regularly. For now, however, I will have to agree with Haney Mallemat and Simon Carley: