The aim of the present study was to assess whether patients with pulmonary embolism (PE) could be managed as outpatients after early discharge from hospital using low molecular weight heparin instead of remaining as in-patients until effective oral anticoagulation was achieved.Phase 1 of the study identified criteria for the safe discharge of selected patients; phase 2 treated a cohort of low-risk patients with PE as outpatients with tinzaparin using existing deep venous thrombosis services.In phase 1, 127 (56.4%) of 225 patients were considered unsuitable for outpatient management. Reasons included: admission for another medical reason; additional monitoring or requirement for oxygen; bleeding disorders; previous PE/further PE while on warfarin; co-existing major deep venous thrombosis; likelihood of poor compliance; significant immobility; and pregnancy. In phase 2, 157 patients with PE received outpatient anticoagulation therapy. There were no deaths, bleeding or recurrent thromboembolic events during acute treatment with low molecular weight heparin. The median (range) length of hospital stay was 1.0 (1-4) day, with a median saving of 5.0 (1-42) bed-days per patient.Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. Early discharge and outpatient management of pulmonary embolism appears safe and acceptable in selected low-risk patients, and can be implemented using existing outpatient deep venous thrombosis services.

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Pulmonary embolism (PE) is a common complication of deep vein thrombosis(DVT). It has been shown that low molecular weight heparin (LMWH) may be used to treat PE and DVT and that home treatment of DVT with LMWH is safe and effective. A study published in 2000 suggested that outpatient management of PE is feasible and safe for the majority of patients. Phase 1 of this study showed that 44% of patients fulfilled criteria for theoretical outpatient management and that there were no bleeding or theomboembolic complications in the LMWH treatment phase in this group suggesting that these patients could safely have been discharged early. In Phase 2 of the study all patients with a confirmed PE (high probability VQ scan, positive CT pulmonary angiogarm or clincal features of PE plus radiologically confirmed DVT) were entered into the early discharge scheme if they fulfilled criteria validated in phase 1, patients consented and they were discharged within 72 hours of presentation. Patients were treated with 175 Anti-Xa IU/kg tinzaparin (Innohep®) daily (for a minimum of 6 days) and oral anticoagulant therapy. Patients were excluded if: age < 18, admission for additional monitoring or treatment, active bleeding or bleeding disorder, poor compliance or morbidity, pregnant, previous PE, co-existing major DVT and patient preference. Outcome data were collected at 3 and 6 months including mortality and thromboembolic or bleeding events (early, whilst receiving LMWH, and late, after cessation of LMWH). Patients were asked to complete a satisfaction score using 10-point visual analogue score at the end of LMWH treatment phase and to indicate their preference for inpatient or outpatient management for any future episodes of PE. 107 patients with confirmed PE across 6 centres were discharged early. All patients completed the acute treatment phase with Innohep® and outcome data for this period were available for 100% patients. 3 month outcome data were available in 93 (86%) patients. There were no bleeding, thromboemblic complications, deaths or related readmissions in the early treatment phase. 1 patient experienced an anxiety episode in the early treatment phase and required reassessment but not readmission. Patients received a mean of 7.6 days of Innohep® and this was continued for a mean of 5.5 days after discharge, indicating that outpatient management of PE saved up to 5.5 inpatient bed days. 79.5% of patients completed the satisfaction score - the mean score was 9.3 indicating that patients were highly satisfied with outpatient treatment. 98% of patients expressed a preference for outpatient management. There were no significant adverse events in the acute LMWH treatment phase indicating that selected patients with a confirmed PE can safely be managed as outpatients in schemes similar to outpatient management of DVT and that this is highly acceptable to patients.

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