- Design
- Single-centre implementation study, before and after
- Population
- 705 low-PESI patients among 1,810 with acute pulmonary embolism
- Primary outcome
- Proportion of low-PESI patients discharged from the ED
- Effect
- 5.1% to 33.3% by year three (OR 9.24, 5.04–16.92); no 30-day recurrence or death after discharge
A quaternary US emergency department introduced a multicomponent programme to tackle barriers to outpatient care of low-risk pulmonary embolism, and tracked it over three years against a three-year baseline. Of 1,810 patients with acute pulmonary embolism, 705 had a low PESI score (85 or less).
Discharge of low-PESI patients rose from 5.1% before the programme to 16.1%, 24.0% and 33.3% over the following three years (year-three OR 9.24, 95% CI 5.04–16.92). Among those discharged, there was no recurrent thromboembolism or death within 30 days, and bleeding was uncommon and never needed admission.
Much of the remaining admission was in patients who met Hestia criteria, which flag social or clinical reasons for admission despite a low PESI. Excluding those, discharge reached 75%. This is a single-centre before-and-after study, but it shows the gap between guideline-supported outpatient care and what happens is mostly a matter of process.
- Calculate PESI or sPESI for every patient with acute pulmonary embolism.
- Apply Hestia criteria alongside to identify reasons a low-score patient still needs admission.
- Arrange anticoagulant supply and early follow-up before discharge.
- No recurrence or deaths occurred at 30 days among discharged patients in this programme.
Why it matters
Most low-risk patients were being admitted out of habit rather than need.
Don't overread it
A single-centre before-and-after study cannot separate the programme's effect from wider changes in practice.
The statistics, in plain English
An odds ratio of 9.24 compares the odds of discharge in year three with the baseline period. Before-and-after studies cannot rule out other changes over the same years, and safety outcomes rest on a modest number of discharged patients.
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