Economic and practical aspects of thromboprophylaxis with unfractionated and low-molecular-weight heparins in hospitalized medical patients.

Clin Appl Thromb Hemost. 2009 Oct;15(5):489-500

Authors: Pineo GF, Hull RD

Acutely ill medical patients are at significant risk of developing venous thromboembolic (VTE) complications during or after their hospitalization. Venous thromboembolic events, such as proximal deep vein thrombosis (DVT) or pulmonary embolism (PE), place a high and unacceptable burden on health care resources, up to US$1.5 billion annually in the United States. However, the burden of VTE can be reduced by use of appropriate thromboprophylaxis. Prophylaxis of VTE with either a low-dose unfractionated heparin (UFH) or a low-molecular-weight heparin (LMWH) in medical inpatients is effective, well tolerated and cost-effective, compared with no prophylaxis. Low-molecular-weight heparins have a number of practical benefits over UFH, including once-daily subcutaneous injection and the potential to be used in the outpatient setting. These clinical advantages could translate to improved patient adherence to therapy and provide economic benefits, where LMWHs are more cost-effective compared with UFH.

PMID: 19520676 [PubMed - indexed for MEDLINE]

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How much do operational processes affect hospital inpatient discharge rates?

J Public Health (Oxf). 2009 Dec;31(4):546-53

Authors: Wong H, Wu RC, Tomlinson G, Caesar M, Abrams H, Carter MW, Morra D

BACKGROUND: The objective of this study is to determine the effect of day of the week, holiday, team admission and rotation schedules, individual attending physicians and their length of coverage on daily team discharge rates. METHODS: We conducted a retrospective analysis of the General Internal Medicine (GIM) inpatient service at our institution for years 2005 and 2006, which included 5088 patients under GIM care. RESULTS: Weekend discharge rate was more than 50% lower compared with reference rates whereas Friday rates were 24% higher. Holiday Monday discharge rates were 65% lower than regular Mondays, with an increase in pre-holiday discharge rates. Teams that were on-call or that were on call the next day had 15% higher discharge rates compared with reference whereas teams that were post-call had 20% lower rates. Individual attending physicians and length of attending coverage contributed small variations in discharge rates. Resident scheduling was not a significant predictor of discharge rates. CONCLUSIONS: Day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Introducing greater holiday and weekend capacity as well as reorganizing internal processes such as admitting and attending schedules may potentially optimize discharge rates.

PMID: 19465455 [PubMed - indexed for MEDLINE]

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Evaluation of direct medical costs of hospitalization for febrile neutropenia.

Cancer. 2010 Feb 1;116(3):742-8

Authors: Lathia N, Mittmann N, DeAngelis C, Knowles S, Cheung M, Piliotis E, Shear N, Walker S

BACKGROUND: Treatment of febrile neutropenia (FN) is costly, because it typically involves hospitalization. As cancer rates continue to increase, the number of patients suffering from FN will also increase, making it important to quantify the costs of treating this condition accurately and comprehensively. METHODS: A consecutive sample of patients admitted to an inpatient hematology/oncology ward at a tertiary care hospital for the treatment of chemotherapy-induced FN was enrolled in this study. Patients were followed prospectively during hospitalization, and information on medical resource utilization including length of stay, medications, and laboratory and diagnostic tests was collected. Costs, extracted from hospital and provincial databases, were used to calculate the overall cost per FN episode, from the hospital perspective. RESULTS: Fifty-one episodes of FN that occurred in 46 patients were included in the study. Approximately 52% of these episodes occurred in women, and 65% of these episodes occurred in patients with hematologic malignancies. The mean +/- standard deviation age of patients was 60.3 +/- 13.4 years. The mean length of stay per episode was 6.8 +/- 4.9 days. The mean overall cost per episode was 6324 +/- 4783 in 2007 Canadian dollars. CONCLUSIONS: Hospitalization for the treatment of FN is expensive. The results of this study could be used in future economic evaluations of preventive measures and treatments for FN, including primary prophylactic administration of hematopoietic growth factors and outpatient treatment of this condition.

PMID: 20029970 [PubMed - indexed for MEDLINE]

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The effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis.

J Am Geriatr Soc. 2010 Jan;58(1):83-92

Authors: Van Craen K, Braes T, Wellens N, Denhaerynck K, Flamaing J, Moons P, Boonen S, Gosset C, Petermans J, Milisen K

OBJECTIVES: To examine how geriatric evaluation and management units (GEMUs) are organized and to examine the effectiveness of admission on a GEMU. DESIGN: Systematic review and meta-analysis based on literature search of multiple databases and the references lists of all identified articles and by contacting authors. SETTING: GEMUs. PARTICIPANTS: Elderly people admitted to a GEMU. MEASUREMENTS: Quality of the studies was assessed on 10 criteria. The outcome parameters were mortality, institutionalization, functional decline, readmission, and length of stay at different follow-up points. A random-effects meta-analysis was performed using Hedges’ gu and variance of relative risk (RR). RESULTS: GEMUs are organized in a heterogeneous way and the included studies gave no thorough description of comprehensive geriatric assessment (CGA). Involvement of a multidisciplinary team was a key element in all GEMUs. The individual trials showed that admission to a GEMU has one or more favorable effects on the outcomes of interest, with two significant effects in the meta-analysis: less functional decline at discharge from the GEMU (RR=0.87, 95% confidence interval (CI)=0.77-0.99; P=.04) and a lower rate of institutionalization 1 year after discharge (RR=0.78, CI=0.66-0.92; P=.003). For the other outcomes in the meta-analysis, a GEMU did not induce significantly different outcomes than usual care. CONCLUSION: This meta-analysis shows a significant effect in favor of the GEMU group on functional decline at discharge and on institutionalization after 1 year. There is heterogeneity between the studies, poor quality of some randomized controlled trials, and shortage of information about CGA. Multidisciplinary CGA offered in a GEMU may add value to the care for frail older persons admitted to the hospital, but the limitations confirm the need for well-designed studies using explicit CGA and more-structured and -coherent assessment instruments such as the Minimum Data Set Resident Assessment Instrument.

PMID: 20002509 [PubMed - indexed for MEDLINE]

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Falls following discharge after an in-hospital fall.

BMC Geriatr. 2009;9:53

Authors: Davenport RD, Vaidean GD, Jones CB, Chandler AM, Kessler LA, Mion LC, Shorr RI

BACKGROUND: Falls are among the most common adverse events reported in hospitalized patients. While there is a growing body of literature on fall prevention in the hospital, the data examining the fall rate and risk factors for falls in the immediate post-hospitalization period has not been well described. The objectives of the present study were to determine the fall rate of in-hospital fallers at home and to explore the risk factors for falls during the immediate post-hospitalization period. METHODS: We identified patients who sustained a fall on one of 16 medical/surgical nursing units during an inpatient admission to an urban community teaching hospital. After discharge, falls were ascertained using weekly telephone surveillance for 4 weeks post-discharge. Patients were followed until death, loss to follow up or end of study (four weeks). Time spent rehospitalized or institutionalized was censored in rate calculations. RESULTS: Of 95 hospitalized patients who fell during recruitment, 65 (68%) met inclusion criteria and agreed to participate. These subjects contributed 1498 person-days to the study (mean duration of follow-up = 23 days). Seventy-five percent were African-American and 43% were women. Sixteen patients (25%) had multiple falls during hospitalization and 23 patients (35%) suffered a fall-related injury during hospitalization. Nineteen patients (29%) experienced 38 falls at their homes, yielding a fall rate of 25.4/1,000 person-days (95% CI: 17.3-33.4). Twenty-three patients (35%) were readmitted and 3(5%) died. One patient experienced a hip fracture. In exploratory univariate analysis, persons who were likely to fall at home were those who sustained multiple falls in the hospital (p = 0.008). CONCLUSION: Patients who fall during hospitalization, especially on more than one occasion, are at high risk for falling at home following hospital discharge. Interventions to reduce falls would be appropriate to test in this high-risk population.

PMID: 19951431 [PubMed - indexed for MEDLINE]

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Long-stay inpatients in short-term emergency units in France: A case study.

Soc Sci Med. 2010 Feb;70(4):501-8

Authors: Gansel Y, Danet F, Rauscher C

Lacking any conventional definition, the phenomenon of so-called “bed-blockers” concerns the issue of long-stay inpatients in short-term units. Our paper explores this question in the context of French Emergency Rooms (ERs) and focuses not on “bed-blocking” as a patient phenomenon but rather on the social constructs developed around these patients by ER professionals. In this paper, we present a case study on one of these “bed-blockers” and venture some hypotheses regarding this phenomenon. On the one hand, it appears as a dysfunction in the healthcare system. Indeed, French ERs take on patients that specialized medical units are reluctant to admit, either because they do not fit into any one specific scientific or clinical category, or because they are not “profitable” when analyzed using care-management tools. On the other hand, bed-blockers play an important role in building a positive identity for the French emergency doctors and personnel performing the “dirty work” of treating them.

PMID: 19926188 [PubMed - indexed for MEDLINE]

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Study of bioaccumulation of dalteparin at a therapeutic dose in patients with renal insufficiency.

J Thromb Haemost. 2009 Oct;7(10):1629-32

Authors: Schmid P, Brodmann D, Odermatt Y, Fischer AG, Wuillemin WA

BACKGROUND: Low-molecular-weight heparins (LMWH) are effective, safe and convenient for anticoagulation. Their use is limited in patients with renal insufficiency (RI) because of bioaccumulation. OBJECTIVES: Evaluate pharmacokinetic data of dalteparin at a therapeutic dose in patients with RI. PATIENTS AND METHODS: Prospective observational cohort study. Inpatients were included into three groups according to glomerular filtration rate (GFR): A > or = 60, B 30-59, C < 30 mL min(-1) 1.73 m(-2). Dalteparin was injected subcutaneously (s.c.) twice daily. Peak plasma anti-factor Xa activity (anti-Xa) was measured and adjusted to applied dose and body weight after the first dose, on day 2, and every 2nd day afterwards. Bioaccumulation factor R was calculated as quotient of the last and the first adjusted anti-Xa. Data are shown as median (interquartile range, IQR). RESULTS: Thirty-two patients (23 men) receiving dalteparin for > or = 2 days were analyzed. Follow-up was 6 days (IQR 4-10, range 2-22). Median dose was 90 (73-106) units kg(-1) per 12 h (P = 0.68). After the first dose, adjusted anti-Xa levels were 3.5 (2.6-5.0), 4.8 (3.3-5.5), 4.5 (3.7-7.5) x 10(-3) for the groups A, B, C; P = 0.26. On the last day, they were 6.1 (3.7-7.3), 7.1 (5.6-8.3), 10.2 (7.8-13.2) x 10(-3); A compared with C, P = 0.002. R was 1.46 (1.15-1.82), 1.36 (1.20-2.16) and 2.28 (1.53-2.93); A compared with C, P = 0.18. CONCLUSION: Therapeutically dosed dalteparin accumulates in patients with severe RI (group C). Dose adjustments according to anti-Xa are recommended for dalteparin if used in this patient population. However, no simple dosing scheme can be suggested yet because of wide inter-individual variation.

PMID: 19624460 [PubMed - indexed for MEDLINE]

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Safety and in-hospital outcomes of bivalirudin use in dialysis patients undergoing percutaneous coronary intervention.

Am J Cardiol. 2010 Feb 1;105(3):297-301

Authors: Delhaye C, Maluenda G, Wakabayashi K, Ben-Dor I, Collins SD, Syed AI, Gonzalez MA, Gaglia MA, Torguson R, Xue Z, Suddath WO, Satler LF, Kent KM, Lindsay J, Pichard AD, Waksman R

Chronic dialysis-dependent patients undergoing percutaneous coronary intervention (PCI) are at a greater risk of bleeding and ischemic events. Bivalirudin has been associated with fewer bleeding complications than unfractionated heparin (UFH) in patients undergoing PCI in various clinical settings. These studies, however, have systematically excluded patients dependent on chronic dialysis. We sought to assess the safety, bleeding rates, and in-hospital outcomes of bivalirudin use compared to UFH use alone in patients requiring dialysis and undergoing PCI. A retrospective analysis of 396 dialysis-dependent patients undergoing PCI from January 2000 to March 2009 was performed. Patients treated with a dose-adjusted bivalirudin regimen (n = 267) were compared to those treated with UFH alone (n = 129). The primary end point of major bleeding (hematocrit decrease > or = 15%, gastrointestinal or intracerebral bleeding) and the composite end point of in-hospital death, nonfatal Q-wave myocardial infarction, and urgent target vessel revascularization were compared between groups. The baseline characteristics were similar between the 2 groups, except for the proportion of men and nonsmokers and body mass index, which were greater in patients treated with bivalirudin. The rate of major bleeding was similar between the bivalirudin and UFH groups (3.4% vs 3.1%, respectively, p = 0.9). The rate of the composite end point (death, Q-wave myocardial infarction, urgent target vessel revascularization) was not significantly different between the 2 groups (1.8% for bivalirudin vs 0.8% for UFH group, p = 0.7). After adjustment, bivalirudin use was not associated with major bleeding (odds ratio 1.23, 95% confidence interval 0.37 to 4.13, p = 0.7). In conclusion, a dose-adjusted bivalirudin anticoagulation regimen for patients requiring chronic dialysis undergoing PCI seems to be as safe and as effective as UFH use alone. These results do not suggest the superiority of bivalirudin over UFH.

PMID: 20102938 [PubMed - indexed for MEDLINE]

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Adverse drug reactions in medical intensive care unit of a tertiary care hospital.

Pharmacoepidemiol Drug Saf. 2009 Jul;18(7):639-45

Authors: Joshua L, Devi P, Guido S

PURPOSE: Patients in the intensive care unit (ICU) have multiorgan dysfunction as well as altered pharmacokinetic parameters. Hence they are susceptible to adverse drug reactions (ADRs). The objective of the study is to assess the characteristics of ADRs among inpatients in the medical ICU and to compare the same with patients who have not experienced ADRs. METHODS: Prospective, observational study for a period of 1 year in medical ICU of a tertiary care hospital. Relevant data of patients with ADRS were analysed. Characteristics of patients with and without ADRs were compared. RESULTS: Of 728 patients admitted in medical ICU, 222 (28.4%) had ADRs. Multiple ADRs (38.7%) implicated by the same drug and serious ADRs (37%) were noticed. Renal/electrolyte system (21%) was most commonly involved. Clinical spectrum included acute renal failure (ARF, 11.4%), hepatic injuries (5.4%), haematological dysfunction (4.2%), seizures (3.3%), upper gastrointestinal bleed (3.3%) and cutaneous ADRs (3.3%). Antimicrobials (27%) were the commonly implicated drug class. The most commonly implicated drug was furosemide (6.8%). Infrequently reported ADRs included azithromycin-induced erythema multiforme, leflunamide-induced erythema multiforme and vasculitis, ceftazidime-induced seizures and ceftriaxone-induced hepatitis. Co-morbidity, polypharmacy and duration of stay were significantly higher in patients with ADRs compared to those who have not experienced ADRs. Three patients died. CONCLUSION: High incidence of serious and multiple ADRs noticed. A wide clinical spectrum of ADRs and infrequently reported ADRs to newer drugs were also observed.

PMID: 19421963 [PubMed - indexed for MEDLINE]

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Physician and nurse perceptions of a new inpatient palliative care consultation project: implications for education and training.

J Palliat Med. 2009 Dec;12(12):1137-42

Authors: Enguidanos S, Housen P, Goldstein R, Vesper E, Allen J, Braun W

BACKGROUND: Few studies have examined ease of integrating palliative care programs into hospital culture. The purpose of this article is to report findings from focus groups conducted among physicians and nurses to elicit their perceptions of an inpatient palliative care team consultation service after 1 year of operation. METHODS: The study consisted of four homogeneous focus groups drawn from a purposive sample of physicians (2 groups; total n = 16) and nurses (2 groups; n = 17) at a large urban managed care center. Structured interview protocols were used to elicit participant perceptions regarding the impact of implementation. Focus groups were audiotaped and transcribed verbatim. We analyzed the data using grounded theory techniques to elicit themes and subthemes. RESULTS: Five major themes emerged regarding the positive and/or transformational impact of the program on patient/family services, medical staff, the hospital, quality of care, and time. Physician and staff observations regarding perceived barriers to integration included subthemes pertaining to the sharing of information, patient/family resistance and cultural differences, and the need for increased services. CONCLUSIONS: The vast majority of comments expressed were related to positive aspects of the program. However, barriers exist that prevent some terminally ill patients from receiving these services. Findings from this study have implications for the need for education and training among providers on palliative and hospice services and, in particular, on the benefits of an inpatient palliative care team for patients, regardless of their attitudes toward end-of-life care programs.

PMID: 19708839 [PubMed - indexed for MEDLINE]

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Treatment of hypertension in the inpatient setting: use of intravenous labetalol and hydralazine.

J Clin Hypertens (Greenwich). 2010 Jan;12(1):29-33

Authors: Weder AB, Erickson S

Acute blood pressure elevations are commonly treated in hospitalized patients. There are no guidelines for appropriate practice and no evidence that such treatment is useful. The authors performed a retrospective review of medical and pharmacy records to determine how often intravenous hydralazine and labetalol are ordered and administered. During a 1-year study period, a total of 29,545 hospitalizations were recorded. The authors identified 2189 patients (7.4% of all patients) for whom 7242 orders were written for hydralazine as needed (10-20 mg per dose) and 5915 for labetalol (10-20 mg per dose). Ordered drugs were administered in 60.3% of patients, and the average number of doses administered was 5.3+/-8.2 (mean +/- SD) for hydralazine and 5.6+/-7.7 for labetalol. Hospital length of stay (LOS) for patients for whom hydralazine was ordered was 12.0+/-15.9 days for those who received at least 1 dose and 7.1+/-9.0 days for those who did not receive a dose (P<.001). For patients for whom labetalol was ordered, patients receiving at least 1 dose had an LOS of 11.8+/-16.1 days vs 7.9+/-10.4 days for those who did not receive a dose (P<.001). Treatment of elevated blood pressure in in-patients is a common practice. The authors suggest that evidence is needed to determine whether the practice is of benefit.

PMID: 20047627 [PubMed - indexed for MEDLINE]

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Soft tissue infections and emergency department disposition: predicting the need for inpatient admission.

Acad Emerg Med. 2009 Dec;16(12):1290-7

Authors: Sabbaj A, Jensen B, Browning MA, John Ma O, Newgard CD

OBJECTIVES: Little empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This study's objective was to generate a clinical decision rule to predict the need for greater than 24-hour hospital admission for patients presenting to the ED with soft tissue infection. METHODS: This was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24-hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression. RESULTS: A total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24-hour admission. Using CART, the strongest predictors of >24-hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37 degrees C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients. CONCLUSIONS: Although we were unable to generate a high-sensitivity decision rule to identify ED patients with soft tissue infection requiring >24-hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24-hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections.

PMID: 20053250 [PubMed - indexed for MEDLINE]

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Unsuspected pulmonary embolism identified using multidetector computed tomography in hospital outpatients.

Clin Radiol. 2010 Jan;65(1):1-5

Authors: Farrell C, Jones M, Girvin F, Ritchie G, Murchison JT

AIM: To evaluate the incidence of unsuspected pulmonary embolism (PE) in an unselected population of outpatients undergoing contrast-enhanced multidetector computed tomography (MDCT) for indications other than the investigation of PE. MATERIALS AND METHODS: Outpatients undergoing CT of the chest over a 6-month period were retrospectively identified and images reviewed. Inpatients and patients undergoing unenhanced CT of the chest were excluded. Data, including referring specialty, patient age and sex, reasons for examination, level of embolism, image quality, and section thickness were recorded. Radiology reports were reviewed with respect to whether or not the embolism was noted at the time of initial reporting. RESULTS: Following exclusions 440 patients were reviewed (195 women and 245 men). PE was identified in 10 of the 440 patients, an incidence of 2.23%. One pulmonary embolus was in the main pulmonary artery, three were in lobar arteries, three in segmental arteries, and three in subsegmental arteries. Patients over the age of 60 years were more likely to have an embolism (9/300, 2.9%) compared with those under 60 years (1/140, 0.7%). Seven of the 10 positive examinations were carried out in patients who were known or later shown to have malignancy. Seven of the 10 emboli were reported at the time of initial reporting. CONCLUSION: The outpatient population has a significant incidence of unsuspected PE. PE should be actively sought when reporting examinations performed for alternative indications, particularly where cancer is a known or suspected diagnosis.

PMID: 20103414 [PubMed - indexed for MEDLINE]

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Increased prevalence of and associated mortality with methicillin-resistant Staphylococcus aureus among hospitalized IBD patients.

Am J Gastroenterol. 2010 Feb;105(2):371-7

Authors: Nguyen GC, Patel H, Chong RY

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) infection has become increasingly prevalent in US hospitals, and the impact of MRSA on hospitalized inflammatory bowel disease (IBD) patients is unknown. METHODS: We used the Nationwide Inpatient Sample to identify admissions for IBD (n=116,842) between 1998 and 2004. We compared prevalence and in-hospital mortality of MRSA among IBD, non-IBD gastrointestinal (GI), and general medical inpatients. RESULTS: MRSA prevalence increased from 4.5/10,000 to 19.0/10,000 over the 7-year period (P<0.0001). After adjustment for confounders, IBD inpatients were at increased risk of MRSA compared with the non-IBD GI (adjusted odds ratio (aOR) 1.61; 95% confidence interval (CI): 1.33-1.96) and general medical (aOR 1.36; 95% CI: 1.11-1.66) groups. Of those with MRSA, catheter-related infections were specifically more common among IBD compared with non-IBD GI and general inpatients (28.8% vs. 11.0% and 8.5%, respectively, P<0.0002). Bowel surgery, parenteral nutrition, and health insurance were predictors of MRSA infection, but the first two became insignificant after controlling for length of stay (LOS). Compared with LOS < or = 7 days, MRSA was more likely among those hospitalized 8-21 days (aOR 7.40; 95% CI: 4.68-11.7) and >21 days (aOR 58.6; 95% CI: 36.0-95.3). MRSA infection was associated with sevenfold increase in mortality (aOR 7.61; 95% CI: 3.33-17.4). CONCLUSIONS: Hospitalized IBD patients are at increased risk of MRSA compared with non-IBD GI and general medical inpatients. Increased mortality in the IBD population associated with MRSA reinforces the importance of measures to prevent nosocomial infection and to reduce length of hospitalization.

PMID: 19809406 [PubMed - indexed for MEDLINE]

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Outpatient treatment of pulmonary embolism.

Swiss Med Wkly. 2009 Nov 28;139(47-48):685-90

Authors: Aujesky D, Mazzolai L, Hugli O, Perrier A

Pulmonary embolism (PE) is traditionally treated in hospital. Growing evidence from non randomized prospective studies suggests that a substantial proportion of patients with non-massive PE might be safely treated in the outpatient setting using low molecular weight heparins. Based on this evidence, professional societies started to recommend outpatient care for selected patients with non-massive PE. Despite these recommendations, outpatient treatment of non-massive PE appears to be uncommon in clinical practice. The major barriers to PE outpatient care are, firstly, the uncertainty as how to identify low risk patients with PE who are candidates for outpatient care and secondly the lack of high quality evidence from randomized trials demonstrating the safety of PE outpatient care compared to traditional inpatient management. Also, although clinical prognostic models, echocardiography and cardiac biomarkers accurately identify low risk patients with PE in prospective studies, the benefit of risk stratification strategies based on these instruments should be demonstrated in prospective management studies and clinical trials before they can be implemented as decision aids to guide PE outpatient treatment. Before high quality evidence documenting the safety of an outpatient treatment approach is published, outpatient management of non-massive PE cannot be generally recommended.

PMID: 20047130 [PubMed - indexed for MEDLINE]

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