Quality statement 6Patients undergoing outpatient management following diagnosis of an acute PE should have an initial review within 7 days of discharge. Subsequent follow-up by a senior clinician with a special interest in PE should take place within a formal pathway.
RationalePatients managed via an outpatient pathway require assessment within the first 7 days to enable:
  • Assessment of ongoing symptoms.

  • Review of concordance with treatment as adequate early anticoagulation is imperative to minimise risk of recurrence.

  • Assessment of side effects, including bleeding complications.

  • A check that limited screening for underlying malignancy has been completed in all patients without known cancer, with referral for more extensive screening in selected cases, dependent on results of the initial investigations.

  • Further discussion regarding PE and expected recovery process.


Subsequent follow-up by a senior clinician with a special interest in PE after 3–6 months enables an individualised plan for ongoing anticoagulation to be made, based on the presence or absence of provoking factors and risk factors for bleeding. It also provides an opportunity to discuss other factors related to PE. Furthermore, it allows assessment of any ongoing symptoms of breathlessness, with subsequent investigations for the presence of chronic thromboembolic pulmonary hypertension in selected cases. This follow-up will most often be provided by a doctor, but in some instances may be a specialist nurse or an advanced practitioner who fulfils the Royal College of Nursing standards (https://www.rcn.org.uk/professional-development/advanced-practice-standards).
Quality measureStructure:
  • Evidence of local arrangements and written clinical protocols and pathways that ensure patients with a new diagnosis of PE are offered robust follow-up.


Process:
  • The proportion of patients with confirmed acute PE who are reviewed within 7 days and subsequently, within an outpatient pathway.


Numerator 1: The number of patients treated via an outpatient pathway with a new diagnosis of PE that receive an initial follow-up* within the first 7 days of discharge.
Denominator 1: The number of patients treated via an outpatient pathway with a new diagnosis of PE.
*Initial follow-up can either be via telephone or face to face.
Numerator 2: The number of patients treated via an out-patient pathway for an acute PE that are reviewed within 6 months of diagnosis, subsequent to their initial 7 day review, by a clinician with a special interest in PE as part of a formal pathway**
Denominator 2: The number of patients treated via an outpatient pathway with a new diagnosis of PE**.
**Local pathways may define certain groups of patients who do not require this later review (eg, patients with certain forms of malignancy). In such instances, these groups of patients should be excluded from the numerator and denominator.
Description of what the quality statement means for each audienceService providers:
  • Ensure systems are in place such that all patients are managed in line with up to date evidence and guidance.

  • Ensure a robust pathway for the outpatient management of patients with PE is in place.

  • Will identify a dedicated clinical lead.


Healthcare professionals:
  • Ensure all patients are referred into a local PE pathway for ongoing assessment and management.


Commissioners:
  • Commission local PE outpatient services to ensure all patients have access to follow-up.


People with confirmed new PE:
  • Expect robust follow-up.

Relevant existing indicators/data sources
  • BTS Guideline for the Initial Outpatient Management of Pulmonary Embolism (2018).2

  • NICE Quality Standards 29 (2016).4

Source references
  • BTS Guideline for the Initial Outpatient Management of Pulmonary Embolism (2018).2

  • Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2015).3