Maureen Salamon

November 02, 2017

WASHINGTON, DC — With a combination of risk stratification, treatment with rivaroxaban (Xarelto, Janssen Pharmaceuticals), and rapid follow-up, more patients with pulmonary embolism can be discharged from the emergency department instead of being admitted to the hospital, new research indicates.

The new protocol is potentially practice-changing for emergency department physicians, said study investigator Christopher Kabrhel, MD, from Massachusetts General Hospital and Harvard Medical School in Boston.

Reducing the hospitalization of patients with pulmonary embolism who present to the emergency department saves healthcare costs without sacrificing patient safety, he added.

We're protecting patients while simultaneously saving money and time.

"We're protecting patients while simultaneously saving money and time," Dr Kabrhel said here at the American College of Emergency Physicians 2017 Scientific Assembly.

"We know that emergency departments are overcrowded, that the length of hospital stays is a major issue, and that decreasing the number of patients in the hospital is, most importantly, good for patients," he told Medscape Medical News.

For their study, Dr Kabrhel and his colleagues assessed patients diagnosed with pulmonary embolism or deep vein thrombosis at two Boston hospitals over a period of 16 months, before and after October 2015, when the outpatient treatment protocol was rolled out at the hospitals. Physicians were educated on the approach, but not required to implement it.

Patients eligible for the protocol were assessed for risk with a combination of clinical factors, including biomarkers, measures of heart strain, and the presence of pulmonary embolism or deep vein thrombosis on ultrasound.

The study involved 2318 patients: 1073 treated before the protocol roll-out and 1245 treated after. Demographic characteristics were similar in the before and after groups.

Overall, the rate of discharge from the emergency department increased from 10.5% to14.8% after the roll-out. But at one of the two hospitals, the increase in discharge rates was more pronounced — from 12.2% to 19.9%.

More patients with pulmonary embolism or deep vein thrombosis were discharged on rivaroxaban after the protocol roll-out than before (58.9% vs 24.2%; P < .001).

Among discharged patients, changes in 7-day mortality, major bleeding, and hospital readmissions were not significantly different before and after the roll-out.

Importance of Follow-up

"Perhaps the most important thing about our protocol is establishing a good system of follow-up for patients," said Dr Kabrhel. The study participants were generally seen again 1 week after discharge.

"Emergency physicians are never going to feel comfortable — nor should they —discharging patients when they're not certain they're going to have the ability to follow up," he explained.

"Follow-up is not terribly difficult," he added, "and should not be a deterrent. Patients will always have a responsibility to follow up, but we want to make it as easy as possible."

Future research should examine the effect of the protocol on emergency department discharges, length of hospital stays, and overall cost-effectiveness, Dr Kabrhel pointed out.

This approach to the outpatient treatment of pulmonary embolism is "extremely feasible," said Brian O'Neil, MD, from the Wayne State University School of Medicine in Detroit.

"What this study shows is that it can be done safely," he told Medscape Medical News, and "at a potentially significant cost savings to the system."

But the quick follow-up care the study participants received, which is vital, "can be difficult to replicate" at some healthcare systems, Dr O'Neill noted.

Dr Kabrhel reports being a consultant for Diagnostica Stago, Genentech, Siemens Healthcare, and Portola Pharmaceuticals; being on the advisory board of BMS/Pfizer, Janssen Pharmaceuticals, Portola, and Boehringer-Ingelheim; and receiving grants from the National Institutes of Health, Diagnostica Stago, Siemens Healthcare, and Janssen Pharmaceuticals. Dr O'Neil has disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2017 Scientific Assembly: Abstract 410. Presented October 31, 2017.

Follow Medscape on Twitter @Medscape and Maureen Salamon @maureensalamon

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