After careful screening of patients in the emergency department, outpatient management of blood clots is less costly and more convenient for patients compared to inpatient care.
Acute pulmonary embolism patients deemed at low-risk for adverse events can be treated safely at home after receiving therapy in an emergency room, recent research indicates.
Acute PE is the third top cause of cardiovascular death, and inpatient treatment has been the historical standard of care for patients. However, a study in CHEST featuring 200 acute PE patients found they could be treated safely at home with outpatient management and anticoagulant medication.
The study's lead author, Joseph Bledsoe, MD, of Stanford University and Intermountain Medical Center, told HealthLeaders this week that home therapy is less costly and more convenient for patients.
"Home-based treatment is really about patient convenience and patient cost savings. Patients are able to sleep in their own beds, spend time with their families, eat their own food, and go to work. By not missing work, they don't have loss of income; and by avoiding the hospitalization, they avoid the associated bills," Bledsoe said.
Treatment at home also avoids risks associated with inpatient care, he said. "Medical errors and hospital acquired infections are an unfortunate complication of hospital admission that can be avoided by home treatment."
Bledsoe and his colleagues, who included researchers from the University of Utah, say their study's 200-patient sample size is small but significant because patients were drawn from five diverse hospitals. "Enrollment of patients from a large tertiary referral hospital and four suburban community hospitals suggests generalizability of our results," they wrote.
Screening patients
Thorough assessments of acute PE patients in the ER are crucial to determine which patients are safe to send home, Bledsoe said.
"PE can be safely treated at home for patients who have been appropriately risk stratified. Using mortality-risk prediction scores, echocardiograms, whole leg ultrasound, cardiac monitoring, and other risk stratification is important to ensure patients will be safely treated at home and minimize the risk of a complication."
Earlier research supports the safety of sending carefully screened acute PE patients home after treatment at an ER, the CHEST study says. "Retrospective analysis has suggested a low PE mortality rate among select patients with PE treated on an outpatient basis, and patients with PE with a good prognosis are unlikely to benefit from inpatient care."
Treating patients
Acute PE patients who participated in the home care study received standardized care.
- Patients were observed for 12 to 24 hours either in an ER bed or a hospital bed under outpatient observation status
- They underwent transthoracic echocardiography and compression ultrasound of both legs as well as compression ultrasound of symptomatic arms
- Treatment featured therapeutic anticoagulation with medications such as enoxaparin and rivaroxaban
- A physician specializing in thrombosis care consulted with each patient while they were under observation
- Outpatient follow-up with a thrombosis physician or the patient's primary care physician was set up before patients were discharged
Follow-up appointments and patient education are key factors to ensure safety, Bledsoe said.
"Educating patients about their diagnosis and treatment, including the possible bleeding risks of treatment, as well as timely outpatient follow-up are important to ensure patient safety. Home treatment of PE is not as simple as identifying the disease, treating, and sending patients home. It takes a thoughtful approach and robust communication with patients."
Christopher Cheney is the CMO editor at HealthLeaders.