Quality statement 3Outpatient management should be offered to all patients with suspected or confirmed acute PE who satisfy clinical risk and exclusion criteria
RationaleOutpatient management of PE is safe in properly selected low-risk patients, with non-inferior rates of recurrent venous thromboembolism, major bleeding, PE-related death and with equivalent patient satisfaction compared with inpatient care.1 9–13 Outpatient management of PE results in reduced length of stay, which may translate to healthcare-related cost savings.10 12 14 15 Outpatient pathways are, however, currently under-utilised.16
Quality measureStructure:
  • Evidence that local arrangements are in place to ensure that eligible patients with suspected or confirmed PE are offered outpatient care.

  • Eligibility for outpatient care should be assessed by clinical risk stratification and assessment of exclusion criteria.


Process:
  • The proportion of eligible patients presenting to hospital with suspected or confirmed PE who are offered outpatient management.


Numerator: The number of patients with suspected or confirmed acute PE who satisfy clinical risk and exclusion criteria who are offered outpatient management.
Denominator: The number of patients with suspected or confirmed PE who satisfy clinical risk and exclusion criteria for outpatient management.
Description of what the quality statement means for each audienceService providers:
  • Should ensure systems and staffing are in place for people with suspected or confirmed PE to be offered outpatient PE management if they fulfil eligibility criteria.


Healthcare professionals:
  • Should ensure people presenting to hospital with suspected or confirmed PE are offered outpatient PE management via a dedicated care pathway if they fulfil eligibility criteria. They should provide adequate information to allow patients to participate in decisions regarding outpatient management.


Commissioners:
  • Should ensure that services are commissioned with sufficient capacity and resources to provide outpatient PE management to those patients fulfilling eligibility criteria.


People who have suspected or confirmed PE:
  • Should be offered outpatient PE management if they fulfil eligibility criteria. To enable them to make an informed decision regarding outpatient management, they should have the opportunity for a discussion regarding the risks and benefits of outpatient care with a healthcare professional who possesses the necessary knowledge and skills.

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

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

  • Home treatment in pulmonary embolism (2010).9

  • Outpatient vs inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial (2011).10

  • Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis (2013)11

  • Early discharge of patients with pulmonary embolism: a two-phase observational study (2007)12

  • Out of hospital treatment of acute pulmonary embolism in patients with a NT-proBNP level (2010).13

  • Investigating and managing suspected pulmonary embolism in an outpatient setting: the Leicester experience (2014)14

  • Home treatment of patients with small-sized to medium-sized acute pulmonary embolism (2014).15

  • Rate and duration of hospitalisation for deep vein thrombosis and pulmonary embolism in real-world clinical practice (2015).16

DefinitionsOutpatient management: patients with confirmed PE are discharged home on the same day as diagnosis while patients with suspected PE may be discharged home following initial assessment to subsequently return to hospital for definitive investigation.
Eligibility criteria: either (a) clinical risk score (eg, PESI or s-PESI) plus clinical exclusion criteria or (b) clinical exclusion score (eg, Hestia) as described in the BTS Guideline for the Initial Outpatient Management of Pulmonary Embolism (2018).2