Adoption of Outpatient Management of Acute Low-Risk Pulmonary Embolism

To assess longitudinal outcomes of a multicomponent intervention designed to address key barriers to the outpatient management of low-risk pulmonary embolism (PE), and to define the most appropriate target population and metric for evaluating adoption.

We implemented a multicomponent intervention in the emergency department (ED) of a quaternary academic medical center. Outcomes were evaluated using the RE-AIM framework, comparing a 3-year preimplementation period (2016-2019) with active implementation (year I), postimplementation (year II), and maintenance (year III) periods. The primary outcome (adoption) was the proportion of low-PESI (≤85) patients discharged from the ED. Following implementation, the charts of all hospitalized low-PESI patients were reviewed to determine reasons for admission.

Among 1,810 patients with acute PE, 705 (39.0%) had low-PESI scores. Adoption rose from 5.1% preimplementation to 16.1% (odds ratio [OR] 3.43, 95% confidence interval [CI] 1.77 to 6.63), 24.0% (OR 5.98, 95% CI 3.04 to 11.78), and 33.3% (OR 9.24, 95% CI 5.04 to 16.92) in years I to III. There were no recurrent venous thromboembolism or deaths within 30 days of any ED discharge. Bleeding complications were rare (0%-4.3%) and none required hospitalization. Hospitalization decreased primarily among low-PESI patients without Hestia criteria, whereas admission of low-PESI Hestia-positive patients remained relatively constant. Excluding Hestia-positive cases, adoption increased from 9.0% preimplementation to 75% in the maintenance phase.

In this single-center implementation study, a multicomponent intervention guided by RE-AIM resulted in a sustained increase in outpatient management of low-risk PE. Both the PESI score and Hestia criteria could be incorporated into the definition of the target population and future quality metrics.