Common issues that have been identified that contribute to unnecessarily long stays, inappropriate resource consumption, or unnecessary hospital stays in patients admitted with a diagnosis of pulmonary embolism include:
- Treating patients with IV heparin followed by warfarin when other, preferred treatment options are available. Guidelines for treatment of DVT and PE in Chest recommend newer oral anticoagulants, the DOAC’s: dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) or edoxaban (Savaysa) as preferred treatment for most patients with VTE.
- Length of stay is significantly impacted by medication choice – it is substantially longer for patients treated with heparin and warfarin (which are no longer the drugs of choice for most DVT/PE patients) than with the DOAC’s.
- Unnecessary testing frequently prolongs hospital stays and adds unnecessary cost to the hospitalization. Common offenders are serial D-dimers, venous Dopplers after a diagnosis of PE has been established, studies that are repeated without any clinical pertinence, and hypercoagulability testing.
- DVT and PE have increasingly been identified as outpatient-only for a significant subset of those with uncomplicated VTE. Any hospitalizations for such low-risk patients should be brief with a rapid turnaround time to discharge.
Suggestions to improve Length of Stay and avoid unnecessary hospital stays and inappropriate resource consumption:
- Avoid IV heparin followed by oral warfarin as treatment for pulmonary embolism unless there is a good clinical reason why the recommended treatment options cannot or should not be used in a particular patient, consistent with the recommendations in the Chest guidelines. Such rationale must be clearly documented in the chart and should be consistent with standard of care.
- For most patients, follow the Chest guidelines and use one of DOAC’s in patients for whom this is indicated – right at the onset of their treatment.
- Directly discuss patients with PCP upon admission and discharge both to assure prompt followup and earlier discharge, and to make sure the PCP understands and concurs with the treatment and discharge plans. It is also useful to identify any other issues that may need to be addressed after discharge. Secure text messaging, adding in a phone number for the PCP to contact you at their convenience for additional discussion or clarification, is a preferred form of contacting the PCP whenever available.
- Identify appropriate candidates with subsegmental PE or isolated distal DVT of the leg who may be candidates for monitoring without treatment according to the Chest guidelines and consider those who are appropriate to discharge without treatment to be followed by PCP.
- Discharge to home to continue treatment promptly as long as hemodynamically stable. Stable patients with otherwise uncomplicated VTE started on DOAC’s should typically be candidates for discharge right away, compared to 5-10 days in the hospital when IV heparin with conversion to warfarin is used.
- Do not perform hypercoagulability workup or request hematology consultation to evaluate for hypercoagulability. Such an evaluation should only be performed when it is clinically indicated and when it influences treatment decisions. Experts indicate that such an evaluation is rarely if ever indicated, yet paradoxically is ordered – at great expense – in many situations where it is neither appropriate nor will the testing affect the care. If you are anticoagulating a patient with VTE, it does not affect hospital treatment decisions, and thus would be more appropriate to perform on an outpatient basis, in the uncommon situation where it would be indicated.
- Avoid consultations and workup of other medical issues that are not so pressing that they need to be done on an inpatient basis. Any additional evaluations that may be useful but can be done on an outpatient basis should both be described on the discharge summary and directly discussed with the outpatient PCP. Pulmonary consultations are often called in PE patients, but unless there is a more complex diagnostic or therapeutic issue or unrelated comorbidity in need of immediate evaluation, these would typically not be needed. When a pulmonary consultation is called, the clinician should discuss the case with the pulmonary consultant to indicate the reason for the referral request. Such discussion should also be documented in the chart.
- Discharge instructions should include not only the medication but also the recommended duration of therapy typically using the Chest guidelines for that recommendation. The summary should also identify any subsequent testing or treatment that may be indicated. Making the transition of care to the outpatient setting effective warrants those recommendations to be communicated to the PCP both directly (STM) and in the discharge summary.
- The PE literature now suggests that many patients can be treated and released from the ER without any hospital stay. Such practices are evolving, and not all patients for whom this may be reasonable are discharged to home from the ER. However, at the least it highlights why patients with uncomplicated VTE, many of whom may not need to be in the hospital at all, should typically be staying in the hospital very transiently, with prompt, timely and medically appropriate discharges.
- Clinical pearl – there is a known association of VTE with malignancy, even preceding the diagnosis of such cancers. There is no indication for a malignancy workup on these patients. However, it is important to note any otherwise unexplained observations – microcytosis, weight loss, abnormal CXR, etc to highlight the need for outpatient followup of such and bring the concern to the attention of the PCP.
