Emergency Department Patient Satisfaction with Treatment of Low-risk Pulmonary Embolism

Abstract

IntroductionMany emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I–III).MethodsThis phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2–8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated.ResultsSurvey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all).ConclusionED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.

Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism

“…Second, we disseminated quarterly research reports to the ED physicians with updates of our ongoing PE studies (Figure 1). Continued research from our own practice setting on the safety and effectiveness of outpatient management for patients with acute PE may have helped communicate that this was becoming a systemwide standard of care …”

“…There is no prompt or best-practice alert. RISTRA-PE includes an autopopulating version of the validated PE Severity Index (eTable 1 in the Supplement) 8,31,32,55 with risk-based recommendations to inform site-of-care decision-making (Table 1) and outpatient exclusion criteria modeled after the Canadian criteria and Hestia clinical decision rule (eFigure in the Supplement). 34,35 Our site-of-care recommendations were designed to be assistive, not directive (eAppendix 3 in the Supplement).…”

“…Second, we disseminated quarterly research reports to the ED physicians with updates of our ongoing PE studies (Figure 1). 7,23,32,33,36,[52][53][54][55][56] Continued research from our own practice setting on the safety and effectiveness of outpatient management for patients with acute PE may have helped communicate that this was becoming a systemwide standard of care. 57 Third, the medical group switched pharmacotherapy recommendations from warfarin to DOACs in 2016 in concert with CHEST guidelines.…”

A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel

“…One survey of emergency physicians found that lack of clear follow-up was the single biggest barrier to outpatient PE treatment, 23 and successful outpatient PE treatment programs described in the literature ensured follow-up with an appropriate clinician after ED discharge. 19,26,92 A patient who is unlikely to follow up after a PE or DVT is not a good candidate for ED discharge.…”

Prognostic Value of D-Dimer in Younger Patients with Pulmonary Embolism

“…Prompt diagnosis, risk assessment and adequate treatment can improve the outcome (7). A reliable risk stratification of PE severity based on the 2019 ESC Guidelines, pulmonary embolism severity index (PESI) or simplified PESI (sPESI) indicates risk of early (inhospital or 30-day) death (8)(9)(10)(11). Adding biomarkers data may help in improving prognosis and categorization of patients with acute PE into risk classes (11)(12).…”