A review on state-of-the-art data regarding safe early discharge following admission for pulmonary embolism: what do we know?

Abstract

Background: Although most patients with acute pulmonary embolism (PE) remain hospitalized during initial therapy, some may be suitable for partial or complete outpatient management, which may have a significant impact on healthcare costs.

Hypothesis: This article reviews the state-of-the-art data regarding recognition of very-low-risk PE patients who are potentially eligible for outpatient treatment, along with the safety, management, and cost-effectiveness of this strategy. We propose an algorithm based on collected data that may be useful/practical for identifying patients truly eligible for early discharge.

Methods: Comprehensive review of scientific data collected from the MEDLINE and Cochrane databases. Studies selected based on potential scientific interest. Qualitative information extracted regarding feasibility, safety, and cost-effectiveness of outpatient treatment, postdischarge management, and selection of truly low-risk patients.

Results: Early discharge of low-risk patients seems feasible, safe, and particularly cost-effective. Several risk scores have been developed and/or tested as prediction tools for the recognition of low-risk individuals: the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva score, the Low-Risk Pulmonary Embolism Decision rule, and the Global Registry of Acute Cardiac Events, among others. PESI is the most well-validated model, offering the safest approach at the current time, especially when combined with additional parameters such as troponin I, N-terminal prohormone of brain natriuretic peptide, and echocardiographic markers of right-ventricular dysfunction.

Conclusions: Recognition of truly low-risk patients entitled to early hospital discharge and outpatient treatment is possible with current risk-stratification schemes along with selected prognostic parameters, and it may have a colossal impact on healthcare costs.

Figure 1

Decision algorithm for the selection of truly low‐risk patients eligible for outpatient treatment, based on previous research. COPD step should include other clinically significant respiratory conditions. Abbreviations: AF, atrial fibrillation; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease.