- Design
- Single-centre before-and-after implementation study
- Population
- 1,810 emergency department patients with acute PE, 705 with PESI 85 or less
- Primary outcome
- Proportion of low-PESI patients discharged from the ED
- Effect
- 5.1% before vs 33.3% in year three (OR 9.24, 95% CI 5.04–16.92); 75% if Hestia-negative
This single-centre implementation study in a US academic emergency department introduced a multicomponent programme to overcome barriers to outpatient management of pulmonary embolism. It compared three years before with three years after, among 1,810 patients, 705 of whom had a low PESI score (85 or less).
Discharge from the emergency department among low-PESI patients rose from 5.1% to 33.3% by year three. Among those also negative on the Hestia criteria, a checklist of social and clinical reasons to admit, discharge reached 75%. No discharged patient had recurrent venous thromboembolism or died within 30 days, and bleeding was uncommon and never needed admission.
The practical lesson is that PESI alone overstates who can go home; adding Hestia identifies the patients for whom outpatient care is realistic. Discharge also needs a reliable route to anticoagulation and follow-up, which is the part most often missing.
- Calculate PESI or sPESI for every patient with confirmed pulmonary embolism.
- Apply the Hestia criteria to identify clinical or social reasons to admit.
- Consider discharge for low-risk, Hestia-negative patients with access to anticoagulation.
- Arrange follow-up within a few days and give clear return advice.
- Confirm the patient can obtain and afford the anticoagulant before they leave.
Why it matters
Many low-risk patients are admitted for want of a pathway, not because they need a bed.
Don't overread it
This is a before-and-after study at one centre, not a randomised comparison.
The statistics, in plain English
The odds ratios compare each year with the period before the programme; an OR of 9.24 in year three means much higher odds of discharge. The absence of 30-day events is reassuring but comes from one centre, so rare harms cannot be excluded.
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