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Akhavan AR, O'Brien-Lambert A, Postiglione N, Schleyer AM, Vrablik M, Hall MK. Impact of an Institutional Clinical Pathway on Emergency Physicians' Stated Preferences in Treating Patients with Low-Risk Pulmonary Embolism. Crit Pathw Cardiol 2023; 22:120-123. [PMID: 37782623 DOI: 10.1097/hpc.0000000000000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool. METHODS We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway. RESULTS Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE. CONCLUSION Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.
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Affiliation(s)
- Arvin Radfar Akhavan
- From the Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Alex O'Brien-Lambert
- From the Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Nick Postiglione
- From the Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Anneliese M Schleyer
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Marie Vrablik
- From the Department of Emergency Medicine, University of Washington, Seattle, WA
| | - M Kennedy Hall
- From the Department of Emergency Medicine, University of Washington, Seattle, WA
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Westafer LM, Jessen E, Zampi M, Boccio E, Casey SD, Lindenauer PK, Vinson DR. Barriers and Facilitators to the Outpatient Management of Low-risk Pulmonary Embolism From the Emergency Department. Ann Emerg Med 2023; 82:381-393. [PMID: 37596016 PMCID: PMC10440853 DOI: 10.1016/j.annemergmed.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/21/2023] [Accepted: 02/28/2023] [Indexed: 08/20/2023]
Abstract
STUDY OBJECTIVE Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism (PE) from emergency departments (EDs) in the US remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of PE from the ED using implementation science methodology. METHODS We conducted semistructured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk PE. We developed an interview guide using the implementation science frameworks-the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process. RESULTS We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of PE. Although outer setting determinants, such as medicolegal climate, follow-up, and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities, and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes. CONCLUSION In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute PE should be informed by these barriers and facilitators, which are aligned with the deimplementation theory.
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Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | - Erica Jessen
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Michael Zampi
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Eric Boccio
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Scott D Casey
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Vacaville Medical Center, Vacaville, CA
| | - Peter K Lindenauer
- Department for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - David R Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Roseville, Medical Center, Roseville, CA
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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Rosovsky RP, Grodzin C, Channick R, Davis GA, Giri JS, Horowitz J, Kabrhel C, Lookstein R, Merli G, Morris TA, Rivera-Lebron B, Tapson V, Todoran TM, Weinberg AS, Rosenfield K. Diagnosis and Treatment of Pulmonary Embolism During the Coronavirus Disease 2019 Pandemic: A Position Paper From the National PERT Consortium. Chest 2020; 158:2590-2601. [PMID: 32861692 PMCID: PMC7450258 DOI: 10.1016/j.chest.2020.08.2064] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/06/2020] [Accepted: 08/16/2020] [Indexed: 12/22/2022] Open
Abstract
The coexistence of coronavirus disease 2019 (COVID-19) and pulmonary embolism (PE), two life-threatening illnesses, in the same patient presents a unique challenge. Guidelines have delineated how best to diagnose and manage patients with PE. However, the unique aspects of COVID-19 confound both the diagnosis and treatment of PE, and therefore require modification of established algorithms. Important considerations include adjustment of diagnostic modalities, incorporation of the prothrombotic contribution of COVID-19, management of two critical cardiorespiratory illnesses in the same patient, and protecting patients and health-care workers while providing optimal care. The benefits of a team-based approach for decision-making and coordination of care, such as that offered by pulmonary embolism response teams (PERTs), have become more evident in this crisis. The importance of careful follow-up care also is underscored for patients with these two diseases with long-term effects. This position paper from the PERT Consortium specifically addresses issues related to the diagnosis and management of PE in patients with COVID-19.
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Affiliation(s)
| | - Charles Grodzin
- Emory University Hospital Midtown, Emory University, Atlanta, GA
| | - Richard Channick
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Jay S Giri
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Geno Merli
- Thomas Jefferson University Hospitals, Philadelphia, PA
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Vinson DR, Aujesky D, Geersing GJ, Roy PM. Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review. Perm J 2020; 24:19.163. [PMID: 32240089 DOI: 10.7812/tpp/19.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. OBJECTIVE To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). METHODS We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. RESULTS We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. DISCUSSION We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. CONCLUSION Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA.,Kaiser Permanente Division of Research, Oakland, CA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, UMR (CNRS 6015 - INSERM 1083) Institut Mitovasc, Université d'Angers, France
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Deitelzweig S, Hlavacek P, Mardekian J, Rosenblatt L, Russ C, Tuell K, Lingohr-Smith M, Lin J, Guo JD. Comparison of inpatient admission rates of patients treated with apixaban vs. warfarin for venous thromboembolism in the emergency department. Hosp Pract (1995) 2020; 48:41-48. [PMID: 31976776 DOI: 10.1080/21548331.2020.1718925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/17/2020] [Indexed: 06/10/2023]
Abstract
Objectives: This study evaluated inpatient admission status, hospitalization length of stay (LOS), hospital costs, and readmissions of patients who were diagnosed with venous thromboembolism (VTE) and treated with apixaban or warfarin in the emergency department (ED).Methods: Patients (≥18 years) with an ED visit with a primary discharge diagnosis code of VTE were identified from the Premier Hospital database (8/1/2014-5/31/2018). Patients who received apixaban or warfarin during the ED visit were selected and grouped into two treatment cohorts. Outcomes of ED disposition (discharged or admitted to the inpatient setting), hospital LOS, hospital cost of index event, and rate of 1-month readmissions were compared for the study cohorts.Results: Of the overall study population, 30.5% (n = 12,174; mean age: 59.7 years) received apixaban and 69.5% (n = 27,767; mean age: 59.3 years) received warfarin for VTE in the ED. After adjusting for patient and hospital characteristics, the regression analysis showed that apixaban was associated with a significantly lower likelihood of admission to the inpatient setting vs. warfarin (Odds Ratio [OR]: 0.12, 95% Confidence Interval [CI]: 0.12 to 0.13; p < 0.001). Correspondingly, mean index hospital LOS was 1.42 days shorter (95% CI: -1.47 to -1.36; p < 0.001) and mean index event hospital cost per patient was significantly lower by $4,276 ($3,732 [95% CI: $3,565 to $3,907] vs. $8,008 [95% CI: $7,676 to $8,355]; p < 0.001). Also, the likelihood of all-cause 1-month readmission was significantly lower for patients treated with apixaban vs. warfarin (OR: 0.85, 95% CI: 0.79 to 0.92; p < 0.001).Conclusions: In the real-world setting, VTE patients with an ED visit who were treated with apixaban vs. warfarin had a lower likelihood of being admitted to the inpatient setting, which was reflected in shorter average LOS and lower average index event cost. Additionally, the risk of 1-month readmission was also lower for patients treated with apixaban vs. warfarin.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | | | | | | | | | | | | | - Jay Lin
- Novosys Health, Green Brook, NJ, USA
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Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, Lin JS, Kene MV, Wang DH, Sax DR, Pleshakov TS, McLachlan ID, Yamin CK, Elms AR, Iskin HR, Vemula R, Yealy DM, Ballard DW. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med 2018; 169:855-865. [PMID: 30422263 DOI: 10.7326/m18-1206] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. OBJECTIVE To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. DESIGN Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676). SETTING All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). PATIENTS Adult ED patients with acute PE. INTERVENTION Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. MEASUREMENTS The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. RESULTS Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. LIMITATION Lack of random allocation. CONCLUSION Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. PRIMARY FUNDING SOURCE Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente Sacramento Medical Center, Sacramento, California (D.R.V.)
| | - Dustin G Mark
- The Permanente Medical Group, Kaiser Permanente Northern California, and Kaiser Permanente Oakland Medical Center, Oakland, California (D.G.M.)
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, and Kaiser Permanente South San Francisco Medical Center, South San Francisco, California (U.K.C.)
| | - Jie Huang
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Mary E Reed
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - James S Lin
- The Permanente Medical Group, Oakland, and Kaiser Permanente Santa Clara Medical Center, Sacramento, California (J.S.L.)
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Leandro Medical Center, Sacramento, California (M.V.K.)
| | | | - Dana R Sax
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Tamara S Pleshakov
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.S.P.)
| | - Ian D McLachlan
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Francisco Medical Center, San Francisco, California (I.D.M.)
| | - Cyrus K Yamin
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Andrew R Elms
- The Permanente Medical Group, Oakland, and Kaiser Permanente South Sacramento Medical Center, Sacramento, California (A.R.E.)
| | - Hilary R Iskin
- University of Michigan Medical School, Ann Arbor, Michigan (H.R.I.)
| | - Ridhima Vemula
- University of Cincinnati College of Medicine, Cincinnati, Ohio (R.V.)
| | - Donald M Yealy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y.)
| | - Dustin W Ballard
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente San Rafael Medical Center, San Rafael, California (D.W.B.)
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Barrett TW, Freeman CL. Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out. Ann Emerg Med 2018; 72:725-730. [DOI: 10.1016/j.annemergmed.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weeda ER, Butt S. Systematic Review of Real-World Studies Evaluating Characteristics Associated With or Programs Designed to Facilitate Outpatient Management of Deep Vein Thrombosis. Clin Appl Thromb Hemost 2018; 24:301S-313S. [PMID: 30428693 PMCID: PMC6714833 DOI: 10.1177/1076029618811082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Select patients with acute deep vein thrombosis (DVT) can be managed as outpatients. We sought to conduct a systematic review of real-world studies describing either (1) the clinical characteristics associated with outpatient DVT treatment in all-comers or (2) emergency department (ED) programs designed to facilitate outpatient DVT treatment. MEDLINE and SCOPUS were searched (January 1, 2012, to May 1, 2018) to identify citations meeting the aforementioned criteria. Twenty-one real-world studies were included. The proportion of all-comer patients with DVT managed as outpatients was ≤50% in 11 of 15 studies. With the exception of younger age, no characteristics were consistently associated with outpatient treatment across the 13 studies reporting these characteristics. We identified 8 studies describing ED programs aimed at facilitating DVT outpatient treatment, all of which provided education and included measures to encourage early outpatient follow-up after ED discharge. In conclusion, the proportion of patients with DVT managed as outpatients across real-world studies was low. Several ED programs aimed at facilitating this treatment have been described. It is possible that programs similar to these will increase the proportion of patients with DVT that can be safely managed as outpatients.
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Affiliation(s)
- Erin R Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Sofia Butt
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
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Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes. Ann Emerg Med 2018; 72:62-72.e3. [DOI: 10.1016/j.annemergmed.2017.10.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 11/20/2022]
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