Initiation of an emergency department discharge pathway for low-risk patients with venous thromboembolism: Factors impact real-world practice

BACKGROUND: We initiated an institutional pathway for the outpatient treatment of low-risk patients with venous thromboembolism (VTE) and evaluated emergency department (ED) discharge rates and safety outcomes before and after pathway initiation. This pathway was augmented by the ability to schedule a 1-week follow-up with an outpatient provider in a vascular medicine clinic, a 30-day direct oral anticoagulant (DOAC) prescription, and anticoagulant education facilitated by the ED clinical pharmacist. METHODS: A retrospective cohort of 1260 patients with VTE presenting to the ED between July 1, 2014, and June 30, 2018, was identified in the electronic health record (EHR) by a natural language processing algorithm scanning radiology reports for the presence or absence of pulmonary embolism (PE) or deep venous thrombosis (DVT). We compared patients who presented 2 years before and 2 years after pathway initiation (July 1, 2016) using a regression model to examine the independent effect of ED pathway initiation on discharge rates. RESULTS: = 685) pathway initiation differed significantly in their prevalence of hypertension, prior hospitalization, and prior PE. Pathway initiation trended toward fewer ED discharges of low-risk patients with VTE (aOR = 0.74, 95% CI: 0.48 to 1.13). Older age, recent hospitalization, prior PE, and higher heart rate (HR) were associated with lower odds of ED discharge. There were no significant increases in ED return visits, hospitalizations, or bleeding events following pathway initiation. CONCLUSIONS: Initiation of a VTE discharge pathway was complicated by an increase in the proportion of patients with recent hospitalizations and prior PE in the postpathway period, which was associated with lower odds of ED discharge.