Redefining Adoption of Outpatient Management of Acute Low-Risk Pulmonary Embolism

Outpatient management of low-risk PE patients is supported by clinical trial data and guideline recommendations. Despite strong evidence, widespread and sustained adoption by ED providers has proven elusive. We engaged stakeholders at our academic medical center, implemented a multi-component intervention based on perceived barriers/facilitators, and used a formal implementation science framework to guide longitudinal evaluation. Our objectives were to 1. assess implementation outcomes across a three-year period and 2. determine the most relevant metric for assessing adoption.

From 4/2021-3/2022 (Year 1), we implemented an intervention consisting of 1. clinician education, 2. an EHR nudge based on automated calculation of the Pulmonary Embolism Severity Index (PESI score), 3. a clinical order set including DOAC vouchers, and 4. follow up clinic within 7-10 days of discharge. The program was actively supported from 4/2022 to 3/2023 (Year 2) and then left in place for a 12-month maintenance period (Year 3). We monitored RE-AIM outcomes and reviewed charts of each admitted patient for presence of Hestia criteria.

Low-risk PE was initially defined as PESI < 86 based on chart review or EHR-embedded calculator. Adoption, defined as the proportion of these patients discharged from the ED, increased from a baseline of 5.1% to 15.8%, 24.7%, and 33.3% in Years 1-3, respectively. Pathway elements were used frequently, including vouchers (61.7%), follow appointments (73.5%), and PESI documentation (79.4%). Bleeding complications were rare (0%, 4.5%, and 2.2% in Years 1-3) and did not require hospitalization. There were no recurrent PEs or deaths within 30 days. Review of admissions showed a relatively constant proportion (58%, 59.1%, and 56.6% in Years 1-3) of PESI < 86 patients with clear Hestia criteria. When these cases were excluded from the definition of low-risk PE, adoption increased from a baseline of 12.3% to 36.5%, 60%, and 75% in Years 1-3.

Out multicomponent intervention produced a sustained increase in discharge of low-risk PE, with adoption increasing during a 12-month maintenance period. Outpatient management was safe, with no major bleeding complications, short-term recurrence or death. Our analysis suggests that PESI score alone, while useful given its potential for automated tracking, may be inappropriate for assessing adoption of outpatient management.