David R Vinson1, Dustin W Ballard2, Jie Huang3, Mary E Reed3, James S Lin4, Mamata V Kene5, Dana R Sax6, Adina S Rauchwerger3, David H Wang7, D Ian McLachlan8, Tamara S Pleshakov9, Matthew A Silver10, Victoria A Clague11, Andrew S Klonecke12, Dustin G Mark13. 1. Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA. Electronic address: drvinson@ucdavis.edu. 2. Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA. 3. Kaiser Permanente Division of Research, Oakland, CA. 4. Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA. 5. Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA. 6. Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA. 7. Department of Palliative Medicine, Scripps Health, San Diego, CA. 8. Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA. 9. Southern California Permanente Medical Group, Pasadena, CA; Department of Emergency Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA. 10. Southern California Permanente Medical Group, Pasadena, CA; Department of Emergency Medicine, Kaiser Permanente San Diego Medical Center, San Diego, CA. 11. Permanente Medical Group, Oakland, CA; Department of Radiology, Kaiser Permanente San Rafael Medical Center, San Rafael, CA. 12. Permanente Medical Group, Oakland, CA; Department of Radiology, Kaiser Permanente Roseville Medical Center, Roseville, CA. 13. Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA; Department of Critical Care, Kaiser Permanente Oakland Medical Center, Oakland, CA.
Abstract
STUDY OBJECTIVE: Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge. METHODS: The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5-day pulmonary embolism-related return visits and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. RESULTS: Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5-day pulmonary embolism-related return visit. Thirty-day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All-cause 30-day mortality was lower in the home discharge group (1.1% versus 4.4%). CONCLUSION: Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes.
STUDY OBJECTIVE:Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatientpulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge. METHODS: The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5-day pulmonary embolism-related return visits and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. RESULTS: Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5-day pulmonary embolism-related return visit. Thirty-day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All-cause 30-day mortality was lower in the home discharge group (1.1% versus 4.4%). CONCLUSION: Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes.
Authors: Laura E Simon; Adina S Rauchwerger; Uli K Chettipally; Leon Babakhanian; David R Vinson; E Margaret Warton; Mary E Reed; Anupam B Kharbanda; Elyse O Kharbanda; Dustin W Ballard Journal: J Am Med Inform Assoc Date: 2019-11-01 Impact factor: 4.497
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Authors: Laura E Simon; Mamata V Kene; E Margaret Warton; Adina S Rauchwerger; David R Vinson; Mary E Reed; Uli K Chettipally; Dustin G Mark; Dana R Sax; D Ian McLachlan; Dale M Cotton; James S Lin; Gabriela Vazquez-Benitez; Anupam B Kharbanda; Elyse O Kharbanda; Dustin W Ballard Journal: Acad Emerg Med Date: 2020-04-02 Impact factor: 3.451
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