Author: Keith Hemmert, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Bill Burns, MD (EM Resident Physician, PGY-3, NUEM) // Expert Reviewer: Matthew Kippenhan, MD
Citation: [Peer-Reviewed, Web Publication] Hemmert K, Burns B (2016, March 15). Journal Club: Immediate Discharge Home of Newly Diagnosed VTE. [NUEM Blog. Expert Peer Review by Kippenhan M]. Retrieved from http://www.nuemblog.com/blog/discharge-of-vte
Low risk venothromboembolism (VTE), comprising both deep venous thrombosis (DVT) and pulmonary embolism (PE), is a common emergency department (ED) complaint, and the treatment thereof - initiation of anticoagulation - is often a reason for inpatient admission, particularly in pulmonary embolism. However, it is an open question if low risk PE patients could safely be started on anticoagulation at home, as is often done in the case of low risk DVT. If a precedent could be established that low risk PE could be discharged to home from the ED and treated safely, it could potentially reduce cost and strain on admissions.
Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis
Can low-risk patients with a newly diagnosed VTE in the ED be safely discharged home?
This was a prospective observational study. The setting was two academic EDs, both urban teaching hospitals. The study was divided into two phases: the ED phase in which the VTE diagnosis was made, and the follow up clinic phase. DVT was diagnosed by ultrasound (US) and interpreted either by vascular medicine physicians or radiologists. PE was diagnosed by CT or VQ scan. In order to qualify as low risk, the Hestia criteria were used, with the POMPE-C tool used to further risk stratify those with malignancy.
Those patients deemed eligible by these criteria were entered into the study. The study protocol included a complete blood count, basic chemistry panel, the option of a single enoxaparin dose (1mg/kg) administered in the ED, and one 15mg rivaroxaban dose (PO) in the ED, prior to discharge home with prescriptions for rivaroxaban (15mg BID for 21 days, then a 1 month prescription for 20mg QD). Subsequent prescriptions were written in follow up clinic visits.
The follow up phase included a phone call 1 or 2 days after discharge to confirm script filling and answer any questions. The first follow up clinic visit was at 2-5 weeks, the second was 3-6 months after the first.
- Recurrent VTE while on therapy
- Recurrent VTE required repeat imaging showing acute DVT or PE
- Significant bleeding while on therapy. Significant bleeding was defined as:
- Major bleeding: >2g/dL acute drop in hemoglobin or >2 unit blood transfusion
- Bleeding in a critical area: Bleeding that contributed to death
- Clinically relevant bleeding: Bleeding that required the patient to make an unscheduled visit to any healthcare provider for evaluation, permanently discontinue rivaroxaban, or significantly alter daily activities
During the course of treatment, zero patients had recurrent or new VTE while on therapy. Three patients had recurrences after completing the course of treatment. Two patients died from causes unrelated to VTE or anticoagulation. Zero patients had major bleeding events.
This study lays a strong foundation for further work to demonstrate the viability and safety of discharging to home low risk VTE. While we here at NMH are often comfortable discharging from the ED low risk DVT, it is rare that we discharge low risk PE. In this study, the authors did just that. However, it should be noted that the authors had in place a rigorous follow up system including phone calls and clinic visits with the authors themselves. Such a system does not currently exist at NMH. However, it is simultaneously a strength in that the authors demonstrated the viability of constructing such a system, screening and enrolling patients in a busy, academic urban hospital much like our own. The study is limited by its size, and by poor clinic follow up rate (25% did not physically follow up in clinic).
Overall, the study offers an encouraging precedent. Although we are not currently prepared to adapt such a strategy at NMH, it seems to me that we could leverage systems already in place to construct a similar protocol and attempt to replicate these results. With powerful enough data, discharging low risk PE could become the standard of care.
Thank you Keith for addressing this interesting topic. While most emergency physicians (EPs) have become very comfortable with outpatient management of DVT, the concept of direct discharge with a diagnosis of PE has had a slower adoption. This study provides some good evidence that certain PE patients, when carefully selected, can be safely discharged directly from the ED.
Of note, this study was published simultaneously with a companion - Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban. Although there are some limitations, it shows a significant cost savings to those patients who are not admitted for traditional anticoagulant therapy.
Some additional points from a clinician standpoint that merit discussion:
- When considering a patient for outpatient management , we need to be mindful of the modified Hestia criteria, ensuring that all criteria are met. While much of the list contains clinical data that is objectively measured, we need to look closely at social factors such as substance abuse and noncompliance that would limit a patient’s eligibility.
- Although Rivaroxaban is on the preferred medication list for Medicaid, some states (including Illinois) require prior approval which is not typically obtained in the ED. Similarly, patients who would qualify for the manufacturer’s medication assistance program (www.jjpaf.org) need to fill out an application, have accompanying documentation from the treating physician, and are subject to a waiting period of up to 3 days to obtain approval. Apixiban offers a free 30 day supply for those filling a first prescription; details are available on the manufacturer’s website. Although such programs make these medications financially accessible, patients may benefit from case management or social work assistance to navigate these programs. In certain cases, patients may need to be discharged with a few days supply of medication (perhaps at cost to the hospital) until they have access to a full outpatient prescription.
- The patients in this study were largely followed in an ED based clinic, which is not typical. Although the point of the study is not to assess if the clinic had any impact on patient safety, ensuring good follow-up for our patients should be a priority. For patients without a primary care provider or unreliable follow-up, this would require an assigned visit to a hospital based clinic or even a repeat ED visit to ensure compliance with treatment and to answer any questions. In community settings where more patients have a primary care doctor, it may in fact be easier to coordinate care and follow-up. However, immediate discharge from the ED will be a culture change for some primary care providers and will require education and buy-in at an institutional level.
- We need to ensure adequate educational information for patients starting any form of anticoagulation. Patients are subjected to significant contradictory information on noval anticoagulants (There are numerous commercials on daytime TV from legal firms soliciting patients with bleeding complications or simply Google “Xarelto and lawsuit”). These are potentially dangerous medications and are worthy of a more in-depth discussion than most prescriptions that come from the ED. At NMH, we are fortunate to have pharmacists on hand in our department who can provide more detailed information, but if this is not available the physician will need to provide this education. Specific written reference material may make this easier.
Matthew Kippenhan, MD, FACEP
Assistant Professor; Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine
- Beam DM, Kahler ZP, Kline JA. Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. Acad Emerg Med. 2015 Jul;22(7):788-95.
- Kahler ZP, Beam DM, Kline JA. Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban. Acad Emerg Med. 2015 Jul;22(7):796-802.