21 November 2012

Discharge a PE? that's crazy talk!

So I recently sent home a patient with a Pulmonary Embolism (PE) for the first time. Or perhaps I should say that that it was the first time I've knowingly sent home a patient with a PE, but that's neither here nor there.

This was an unusual case, to be sure. The patient was young and healthy, a triathlete in exceptional condition. He had had arthroscopic surgery on his left knee about a month ago, and a few days after that developed this sharp pleuritic left chest pain. The pain was quite severe, but he ignored it for about three weeks until finally, since it wasn't going away he presented to his doctor, who diagnosed the PE on CT and sent him to me for treatment.

The PE was small but not tiny, segmental as I recall. He otherwise looked great, with no tachycardia or shortness of breath. Functionally, he was doing great. He wasn't back to running yet, but he was cycling and swimming and performing at about his usual level. So I guess that made him functionally "well-preserved." Given that he had symptoms for over three weeks, I guess that qualified him as stable, so we started him on low molecular weight heparin (LMWH) and sent him home.

And I suspect that this is where we are going in the future - outpatient management of stable PE patients.

I threw out the question on twitter at 2AM, and woke to find a vigorous conversation ongoing on the topic among ER physicians on three continents, including one principle investigator of a major trial on the topic. Twitter is awesome. You can read the conversation, in part, here on Storify. Michelle Lin over at Academic Life in Emergency Medicine put together a PV Card on the topic and received some more feedback.The consensus was that most non-US ER docs have already or are beginning to embrace the concept of risk stratifying and discharging some PE patients, while the US practice has not moved much and is deeply skeptical of the idea.

Can we safely send home some PE Patients? 

There are many patients with PEs who are clearly ill. They're easy to spot if you've a smidgen of clinical judgement - they're dyspneic, tachycardia, hypoxic, hypotensive, etc. There is a nicely validated scoring system to sort out those who are more likely to have a bad outcome, and presumably, these folks are the ones who would benefit from hospitalization. But, of the well-appearing PEs with lower risk, the risk is still not zero. There are some people who present with small clots who will proceed to have recurrent embolic events and die. We've all seen it. Is it possible to quantify how commonly that happens? More importantly, is it possible to predict which of the well-seeming patients are more likely to have these bad outcomes?

There is some research out there to support a selective approach to outpatient management of PEs. There was this study which supported the safety of early discharge. More recently there is the Hestia trial which was a prospective study supporting the safety of outpatient treatment, and one unblinded randomized controlled trial of outpatient treatment which also supported outpatient management. If you haven't, I would strongly encourage you to listen to Rob Orman's ERCast podcast on this topic.

I would also add that the value of inpatient treatment as currently practiced seems limited. The well-appearing PEs in the US tend to get a very brief inpatient stay, less than 24 hours, which I suppose might screen for stability but I'm not sure there's any evidence to support the utility of the brief admission. Talking with some european docs, not only is outpatient management common over there (in some countries), it can take 3 days to get a CT-PA, so in many cases they are discharging suspected PEs on LMWH until they get their study, and if it's positive then they get admitted. (Which makes no sense at all, but there you have it.)

The signs seem pretty clear: low-risk patients, as judged by an objective risk stratification score like PESI plus some good old-fashioned clinical judgement (size and location of clot, total clot burden, risk indicators maybe not built into PESI) probably will allow us to safely discharge patients with PE. But can we get there? I'm not sure. The culture of the ER, especially with a perceived high-mortality diagnosis like PE, is highly risk-averse. Merely mentioning the notion elicits gasps of horror from my colleagues, and mutters of "over my cold, dead body." A further, and larger, obstacle to changing practice is our zero-risk-tolerance, highly litigious medical environment. Who wants to be the first ER doc sued for sending home a PE? Plaintiffs' experts will be lining up around the block to testify against you.

And this is a problem. We know that some people with PE will suffer recurrent embolic events despite anticoagulation, though it's a small number. Being hospitalized will not prevent the recurrent embolization, though it may provide earlier detection and therapy. Since we do not know in advance among the low-risk group who will suffer recurrent emboli, it's a catch-22. You can admit them all, a very large number of patients, to detect a very rare complication, or send them home with the risk that when a complication does happen, you are ar risk for being "blamed" for the decision to discharge.

I think we are not ready for prime time here, but it's coming. US docs will demand better data before warming to the notion. Strong institutional support will be needed from hospitals, meaning defined care protocols supporting the practice, in order to convince skittish doctors that they have the backing of the facility in the event of a bad outcome.

You've been warned.

5 comments:

Apsalar said...

I was discharged from the ER with bilateral PE last year. I had no pain, just shortness of breath while working out and increasingly with things like going up stairs. I'd had it for probably 2 months (tracked back to an undiagnosed DVT 3 months earlier), so "stable" seems about right. They actually gave me the option of being admitted if I wanted it, but I'd have rather been in my own bed than a hospital bed.

Dr. J said...

In Canadian EDs we have been sending home low risk PEs for years. A shot of LMWH and a referral to anti-coagulation clinic, if they are not unstable (PESI, gestalt or some other system) how will they possibly benefit from an inpatient stay?
The next frontier is to just start them on oral rivaroxiban in the ED....ad that's it, treatment accomplished.
Dr. J

Lynda Halliger-Otvos said...

In Moscow in July 2008 my 49 y/o sister with no PH was sent home pending an angiogram and died suddenly two mornings later. Bilateral PE was diagnosed on autopsy. My BIL brought her to his home in OK and we buried her there under baking August sun.

I still struggle to recover.

tyro said...

Lynda, I'm sorry for your loss. Your situation shows why folks will be scared to send this home. However, no one's saying we should send home undiagnosed PE or unstable PE; rather, for small PEs in stable patients, there is not a benefit to hospitalization. Groups who stay and groups who go will both have a small risk of recurrent DVT even on anticoagulation and a small risk of problems with the medications. Given that keeping someone in the hospital doesn't seem to help, wouldn't most patients want to go home after being properly diagnosed and risk-stratified?

If this is to be done in the US, it should be done as a group or healthcare system with a protocol and probably pulmonology or cardiology on board, with PMD follow up. I'd like to float the idea but I'm not about to do it all my lonesome, even though I believe that stable, low-PESI score PE should be sent home.

Joe Lex said...

My PEs were in September 2001 - 5 segments by V/Q in those pre-CT angio days. My only symptom was (get ready to grimace), "Doc, I just can't breathe right." HR = 84, RR = 14. Got the diagnosis, said "thank you" and didn't even think about staying in hospital overnight. Self-injected LMWH for ten days and 7 months on warfarin.