Safely Sending PE Out the Door
June 25, 2018
Written by Vivian Lei
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Discharging low risk PE patients from the ED on rivaroxaban resulted in overall shorter hospital length of stay and lower costs without any increase in serious adverse events.
Why does this matter?
Traditionally, almost all patients with a newly diagnosed PE have been hospitalized to initiate anticoagulation. However, a growing body of literature supports discharging low risk PE patients on a direct oral anticoagulant. It appears to be as safe as standard of care and much more cost effective.
PE…OTD
There seems to be even more evidence to support discharging patients with low risk pulmonary embolism from the ED. In this multicenter, US-based, prospective RCT, 114 adult patients diagnosed with low risk PE were randomized to early ED discharge on rivaroxaban or standard of care. Patients were categorized as low risk based on absence of any of the adapted Hestia Criteria. Patients were also excluded for a positive troponin value, contraindication to anticoagulation, or if the investigator determined there was a barrier to treatment or follow-up. Patients who were discharged early had a mean overall duration of hospital stay of 4.8 hours compared to 33.6 hours for patients treated with standard of care. There was no increase in recurrent VTE, VTE-related death, or bleeding events. And the outpatient option saved about $3000.
Source
Emergency Department Discharge of Pulmonary Embolus Patients. Acad Emerg Med. 2018 May 14. doi: 10.1111/acem.13451. [Epub ahead of print]
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One issue I have with this article is the difference (or lac thereof) between the ED Discharge vs SOC groups. The majority of SOC group went on a DOAC and half revaroxaban (same as the ED Discharge group in question). Though using a DOAC is now an acceptable SOC for PE, I wonder if most facilities initiate DOACs for PE this frequently. I would imagine much more still get bridged to Warfarin. Admitting to initiate anticoagulation only really makes sense if you are admitting to bridge to Warfarin. As they note >75% of SOC recieved Heparin despite >75% also going onto DOACs. Since we arent supposed to bridge to DOACs anyway, what was the point of that?