Creating a Safe Discharge Pathway for Low-Risk PE Patients in the ED

From the 2023 HVPA National Conference

Valerie Gavrila MPH (Michigan Medicine), Anthony Cuttitta MPH, Elizabeth Joyce MD, MSc, Colin Greineder MD, Geoffrey Barnes MD, MSc

Background:
Emergency Department (ED) patients diagnosed with a pulmonary embolism (PE) are typically admitted to the hospital, which may increase patient burden, limit inpatient access, and adds significant health system costs. In recent years, a growing body of evidence supports safe same-day discharge of patients diagnosed with low-risk PEs, as defined by the Pulmonary Embolism Severity Index (PESI).
Through a retrospective chart review, our institution discovered we were only discharging 2% of PE cases per year, despite up to 20% of cases being eligible for discharge. 

Objective:
To create a comprehensive and safe discharge pathway for low-risk PE patients in the ED that would alert providers of potential use cases, eliminate barriers for patients that would hinder treatment at home, and ensure timely follow-up after discharge.

Methods:
Leaders in Emergency Medicine and Cardiology assembled a multi-disciplinary team to implement a safe-discharge pathway in the ED for low-risk PE patients that included:

1) Embedded patient risk calculator
An automated PESI calculator was built into the electronic health record (EHR).
2) Best Practice Alert (BPA): A BPA was triggered to fire only if the calculated PESI score was 85 or below at the time of a CT scan for a suspected PE to nudge the provider towards home management.
3) Order Set: A comprehensive EHR order set was created to streamline crucial discharge elements. This included the first oral anticoagulant dose to be given in the ED followed by a one-month outpatient prescription, details for a one-month medication voucher, and scheduling rapid follow-up within 10 days.

For 12 months, the team tracked discharges, follow-up visits, return ED visits, and other important variables using EHR data.

Results:  
In the pilot year, 27 patients were discharged using the pathway, and 19 (70%) of patients were seen for follow-up in an outpatient setting. Six patients (22.2%)
had at least 1 return visit to the ED relating to their PE within 30 days, 5 of which were discharged home and 1 left against medical advice. Five of the six patients had an additional ED visit, with only 3 related to the PE. Those with multiple ED-visits typically had complex medical histories.

Conclusion:
After a pilot year of data, it can be reasonably concluded that low-risk PE patients can be safely discharged home given the proper resources and infrastructure. Patient follow-up data supports there is a low volume of patients re-reporting to the emergency department for PE-related reasons, and an even lower percentage of previously discharged patients requiring additional care related to their PE.

Clinical Implications:
This risk-stratification and care pathway could be expanded to other health systems and related conditions (e.g., deep vein thrombosis) to further reduce unnecessary hospital admissions. Key aspects include the engagement of multi-disciplinary teams, use of automated calculators and behavioral nudges, detailed understanding of current work flow, and integration of strategies into the work flow process.

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