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Amin KD, Weissler EH, Ratliff W, Sullivan AE, Holder TA, Bury C, Francis S, Theiling BJ, Hintze B, Gao M, Nichols M, Balu S, Jones WS, Sendak M. Development and Validation of a Natural Language Processing Model to Identify Low-Risk Pulmonary Embolism in Real Time to Facilitate Safe Outpatient Management. Ann Emerg Med 2024; 84:118-127. [PMID: 38441514 DOI: 10.1016/j.annemergmed.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 07/22/2024]
Abstract
STUDY OBJECTIVE This study aimed to (1) develop and validate a natural language processing model to identify the presence of pulmonary embolism (PE) based on real-time radiology reports and (2) identify low-risk PE patients based on previously validated risk stratification scores using variables extracted from the electronic health record at the time of diagnosis. The combination of these approaches yielded an natural language processing-based clinical decision support tool that can identify patients presenting to the emergency department (ED) with low-risk PE as candidates for outpatient management. METHODS Data were curated from all patients who received a PE-protocol computed tomography pulmonary angiogram (PE-CTPA) imaging study in the ED of a 3-hospital academic health system between June 1, 2018 and December 31, 2020 (n=12,183). The "preliminary" radiology reports from these imaging studies made available to ED clinicians at the time of diagnosis were adjudicated as positive or negative for PE by the clinical team. The reports were then divided into development, internal validation, and temporal validation cohorts in order to train, test, and validate an natural language processing model that could identify the presence of PE based on unstructured text. For risk stratification, patient- and encounter-level data elements were curated from the electronic health record and used to compute a real-time simplified pulmonary embolism severity (sPESI) score at the time of diagnosis. Chart abstraction was performed on all low-risk PE patients admitted for inpatient management. RESULTS When applied to the internal validation and temporal validation cohorts, the natural language processing model identified the presence of PE from radiology reports with an area under the receiver operating characteristic curve of 0.99, sensitivity of 0.86 to 0.87, and specificity of 0.99. Across cohorts, 10.5% of PE-CTPA studies were positive for PE, of which 22.2% were classified as low-risk by the sPESI score. Of all low-risk PE patients, 74.3% were admitted for inpatient management. CONCLUSION This study demonstrates that a natural language processing-based model utilizing real-time radiology reports can accurately identify patients with PE. Further, this model, used in combination with a validated risk stratification score (sPESI), provides a clinical decision support tool that accurately identifies patients in the ED with low-risk PE as candidates for outpatient management.
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Affiliation(s)
- Krunal D Amin
- Department of Medicine, Duke University School of Medicine, Durham, NC.
| | | | | | | | - Tara A Holder
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Cathleen Bury
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Samuel Francis
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | | | | | - Michael Gao
- Duke Institute for Health Innovation, Durham, NC
| | | | - Suresh Balu
- Duke Institute for Health Innovation, Durham, NC
| | - William Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Mark Sendak
- Duke Institute for Health Innovation, Durham, NC
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Kadakia KT, Bikdeli B. Triaging early discharge for pulmonary embolism: home is where the heart(/lung) is. Eur Heart J 2024:ehae358. [PMID: 39010836 DOI: 10.1093/eurheartj/ehae358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Affiliation(s)
| | - Behnood Bikdeli
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Yu A, Birkemeier KL, Mills JR, Kuo T, Tachikawa N, Dai F, Thakkar K, Cable C, Brenner A, Godley PJ. Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management. Cardiol Ther 2024:10.1007/s40119-024-00370-9. [PMID: 38773006 DOI: 10.1007/s40119-024-00370-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). METHODS A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. RESULTS Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. CONCLUSION Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.
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Affiliation(s)
- Anthony Yu
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | | | - J Rebecca Mills
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Tiffany Kuo
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Nina Tachikawa
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Feng Dai
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Karishma Thakkar
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Christian Cable
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Allison Brenner
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Paul J Godley
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA.
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Nopp S, Bohnert J, Mayr T, Steiner D, Prosch H, Lang I, Behringer W, Janata-Schwatczek K, Ay C. Early discharge and home treatment of patients with acute pulmonary embolism in the tertiary care setting. Intern Emerg Med 2024; 19:191-199. [PMID: 37670173 PMCID: PMC10827840 DOI: 10.1007/s11739-023-03415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/26/2023] [Indexed: 09/07/2023]
Abstract
Acute pulmonary embolism (PE) is a potentially life-threatening disease. Current guidelines suggest risk-adapted management. Hospitalization is required for intermediate- and high-risk patients. Early discharge and home treatment are considered safe in the majority of low-risk patients. In this study, we describe characteristics, discharge, and outcome of outpatients diagnosed with acute PE at a tertiary care center. All outpatients undergoing computed tomography pulmonary angiography or ventilation/perfusion lung scan between 01.01.2016 and 31.12.2019 at the University Hospital Vienna, Austria, were screened for a PE diagnosis. Electronic patient charts were used to extract characteristics, clinical course, and outcomes. Within the 4-year period, 709 outpatients (median age: 62 years, 50% women) were diagnosed with PE. Thirty-three (5%) patients were classified as high-risk, 159 (22%) as intermediate-high, 332 (47%) as intermediate-low, and 185 (26%) as low-risk PE according to the European Society of Cardiology risk stratification. In total, 156 (22%) patients (47% with low-risk and 20% with intermediate-low-risk PE) were discharged as outpatients and received home treatment. Rates for home treatment increased 2.4-fold during the study period. Thirty-day mortality in the entire population was 4.9%. All low-risk patients and all but one patient with home treatment survived the first 30 days. Home treatment significantly increased over time and seems to be safe in routine clinical practice. Notably, one in five intermediate-low-risk patients was discharged immediately, suggesting that a subpopulation of intermediate-low-risk patients may also be eligible for home treatment.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Julia Bohnert
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Mayr
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daniel Steiner
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Clinical Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Westafer LM, Jessen E, Zampi M, Boccio E, Casey SD, Lindenauer PK, Vinson DR. Barriers and Facilitators to the Outpatient Management of Low-risk Pulmonary Embolism From the Emergency Department. Ann Emerg Med 2023; 82:381-393. [PMID: 37596016 PMCID: PMC10440853 DOI: 10.1016/j.annemergmed.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/21/2023] [Accepted: 02/28/2023] [Indexed: 08/20/2023]
Abstract
STUDY OBJECTIVE Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism (PE) from emergency departments (EDs) in the US remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of PE from the ED using implementation science methodology. METHODS We conducted semistructured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk PE. We developed an interview guide using the implementation science frameworks-the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process. RESULTS We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of PE. Although outer setting determinants, such as medicolegal climate, follow-up, and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities, and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes. CONCLUSION In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute PE should be informed by these barriers and facilitators, which are aligned with the deimplementation theory.
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Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | - Erica Jessen
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Michael Zampi
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Eric Boccio
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Scott D Casey
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Vacaville Medical Center, Vacaville, CA
| | - Peter K Lindenauer
- Department for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - David R Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Roseville, Medical Center, Roseville, CA
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O’Hare C, Grace KA, Schaeffer WJ, Hyder SN, Stover M, Liles AL, Khaja MS, Cranford JA, Kocher KE, Barnes GD, Greineder CF. Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings. JAMA Netw Open 2023; 6:e2311455. [PMID: 37256624 PMCID: PMC10233419 DOI: 10.1001/jamanetworkopen.2023.11455] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 03/19/2023] [Indexed: 06/01/2023] Open
Abstract
Importance Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools. Objective To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE. Design, Setting, and Participants This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022. Main Outcomes and measures The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) . Results Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001). Conclusions and Relevance In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.
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Affiliation(s)
- Connor O’Hare
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Kelsey A. Grace
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - William J. Schaeffer
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Now with Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - S. Nabeel Hyder
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor
| | - Michael Stover
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Amber L. Liles
- Department of Radiology, Division of Interventional Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor
| | - Minhaj S. Khaja
- Department of Radiology, Division of Interventional Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor
| | | | - Keith E. Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D. Barnes
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor
| | - Colin F. Greineder
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Pharmacology, University of Michigan, Ann Arbor
- BioInterfaces Institute, University of Michigan, Ann Arbor
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Assayag F, Georges JL, Chabay S, Lancien S, Flaujac C, Azarian R, de Villepin EG, Tapiéro S, Livarek B, Koukabi M, Maurizot A. [Home treatment of low-risk pulmonary embolism patients : Efficacy and safety of an outpatient program including the general practitioner]. Ann Cardiol Angeiol (Paris) 2022; 71:245-251. [PMID: 35940966 DOI: 10.1016/j.ancard.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
AIM Outpatient treatment (OT) of patients with low-risk pulmonary embolisms (PE) is recommended. A multidisciplinary OT program including the general practitioner (GP) has been implemented at Versailles hospital in 2019. The objectives of the study were to assess the feasibility, safety and acceptability of the program. MATERIAL AND METHODS The feasibility of, and the inclusion criteria for OT were defined from a retrospective cohort study of PE patients carried out in 2018. In the prospective study, consecutive patients consulting in the emergency department between 2019 and 2021 with confirmed PE were eligible for OT if they had sPESI and HESTIA scores equal to 0, normal troponin and NT-pro-BNP levels, and no right ventricular dilation on imaging. PEs associated with COVID were excluded. The OT program included 4 appointments within 3 months, including 2 with the GP. Events (death, recurrence of PE or venous thromboembolism, bleeding, rehospitalisation) were collected at 3-month follow-up. RESULTS In the retrospective study, 19% of the 138 PE patients seen in the emergency department were eligible for OT. No complication occurred at Day 90. In the prospective study, 313 consecutive patients with confirmed PE in the emergency department were included, 66 (21%) were eligible for OT. Overall, 43 patients (14%) received OT (39 eligible) and 27 patients eligible for OT were hospitalised (92% because of pulmonary infarction). At 3-month follow-up, there were no death, no recurrence of thromboembolism, and one patient has been early hospitalised for COVID; 3 female patients treated with rivaroxaban had minor bleeding (heavy menstrual bleeding). The satisfaction rate of general practitioner was 95%. CONCLUSIONS This study confirms the feasibility and safety of our OT program for low-risk EP patients, centered on the general practitioner. It reduces the time spent in the emergency department, reduces hospitalisations and strengthens the city-hospital link for care.
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Affiliation(s)
- Franck Assayag
- Service de cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France; Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France.
| | - Jean-Louis Georges
- Service de cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Simon Chabay
- Unité de Médecine Vasculaire, Service de Cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Solène Lancien
- Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Claire Flaujac
- Laboratoire de biologie médicale - secteur d'hémostase, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Reza Azarian
- Service de pneumologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Eve Galouzeau de Villepin
- Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Stéphanie Tapiéro
- Unité de Médecine Vasculaire, Service de Cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Bernard Livarek
- Service de cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Mehrsa Koukabi
- Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Aurélien Maurizot
- Unité de Médecine Vasculaire, Service de Cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
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Hernandez‐Nino J, Thomas M, Alexander AB, Ott MA, Kline JA. Communication at diagnosis of venous thromboembolism: Lasting impact of verbal and nonverbal provider communication on patients. Res Pract Thromb Haemost 2022; 6:e12647. [PMID: 35071970 PMCID: PMC8760606 DOI: 10.1002/rth2.12647] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/27/2021] [Accepted: 11/24/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Establishing trust and effective communication can be challenging in the emergency department, where a prior relationship between patient and provider is lacking and decisions have to be made rapidly. Venous thromboembolism (VTE) represents an emergent condition that requires immediate decision making. OBJECTIVE The aim of this paper was to document the experiences, perceptions, and the overall impact of health care provider communication on patients during the diagnosis of VTE in the emergency department. METHODS This was a qualitative method study using semistructured interviews to increase understanding of the patient experience during the diagnosis of VTE and impact of the health care provider communication on subsequent patient perceptions. RESULTS A total of 24 interviews were conducted. Content analysis revealed that certain aspects of health care providers' communication-namely, word choice, incomplete information, imbalance between fear over reassurance and nonverbal behavior-used to deliver and explain VTE diagnosis, treatment, and prognosis increases patients' fears. CONCLUSION These interviews elucidate areas for improvement of communication in the emergency care setting for acute VTE.
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Affiliation(s)
| | - Mary Thomas
- Indiana University School of MedicineIndianapolisIndianaUSA
| | - Andreia B. Alexander
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Mary A. Ott
- Department of PediatricsIndiana University School of MedicineIndianaIndianapolisUSA
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. 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. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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10
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Galaviz KI, Barnes GD. Implementation Science Opportunities in Cardiovascular Medicine. Circ Cardiovasc Qual Outcomes 2021; 14:e008109. [PMID: 34148352 PMCID: PMC8292203 DOI: 10.1161/circoutcomes.121.008109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Karla I Galaviz
- Indiana University School of Public Health-Bloomington (K.I.G.)
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center and Michigan Program on Value Enhancement, University of Michigan Health System (G.D.B.)
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11
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Stubblefield WB, Kline JA. Outpatient treatment of emergency department patients diagnosed with venous thromboembolism. Postgrad Med 2021; 133:11-19. [PMID: 33840338 DOI: 10.1080/00325481.2021.1916299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious, patient-centered, and cost-effective care. From a patient perspective, outpatient treatment of VTE can been simplified by the use of direct oral anticoagulant (DOACs) medications, and is supported by clinical trial evidence, and clinical practice guidelines from international societies. Outpatient treatment of patients with DVT has been more widely accepted as a best practice, while adoption of outpatient treatment of low-risk patients with acute PE has lagged. Many acute care clinicians remain wary of discharging patients with PE, concerned about drug access, adherence, and follow-up. Patients with VTE should be risk stratified identically as emerging evidence has demonstrated efficacy and safety in the interdependence of acute care protocols for the outpatient treatment of low-risk DVT and PE. Clinicians who practice in the acute care setting should be comfortable with risk stratification, anticoagulation, and discharge of low-risk VTE.
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Affiliation(s)
- William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center Nashville United States
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, USA
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