Volume 184 - Issue 3
Safety of hospital in the home
Authors: Bin Soo Ong, Margaret A Karr, Daniel K Y Chan, Anthony Frankel and Qing Shen
Med J Aust 2006; 184 (3): 142-144. || doi: 10.5694/j.1326-5377.2006.tb00164.x
Published online: 6 February 2006
Published online: 6 February 2006
Bin Soo Ong,* Margaret A Karr,† Daniel K Y Chan,‡ Anthony Frankel,§ Qing Shen¶
* Director, Department of Ambulatory Care, † Research Manager, ‡ Director, ¶ Research Assistant, Department of Aged Care and Rehabilitation, § Respiratory Physician, Bankstown-Lidcombe Hospital, Locked Mail Bag 1600, Bankstown, NSW 2200. bin.ongATswahs.nsw.gov.au
In reply: We acknowledge the concerns of Cheng and colleagues regarding the safety of patients with pulmonary embolism (PE) treated in an ambulatory care setting. Caution is important as this is a relatively new area of treatment in ambulatory care compared with the management of deep venous thrombosis. The main objective of our study was to describe our experience in the management of PE in ambulatory care; it was not a randomised controlled study to conclusively define safety as such.
As stated in our paper, there have been reports of the management of PE in the ambulatory care setting.1,2 We now know that more than 90% of patients with sub-massive PE will have a good response to treatment. The challenge is to accurately define this group. The mortality rate we quoted of less than 5% was derived from a review article on prognosis of patients with PE.3 This article quoted three studies on sub-massive PE, one of which was referenced by Cheng and colleagues in their letter.4 We note also that the specific study that was referenced4 included patients with cyanosis and shock; these patients would have been excluded by our selection criteria.
We do not advocate management of all patients with sub-massive PE in the ambulatory care setting. It is also important to be conservative initially in the selection of these patients. There have been various studies examining prognostic indicators for PE, which we have referenced in our paper. There is evidence now that, for patients with specific prognostic indicators, the risk of death and adverse outcomes is significant and such patients should always be admitted.
The practice of managing patients with sub-massive PE should only occur in ambulatory care units which are appropriately resourced, have strict admission criteria and well defined protocols and specialist medical input, consistent with the recommendation of the British Thoracic Society.5 In the meantime, further studies are required before this becomes standard practice in ambulatory care or hospital-in-the-home units.
References
- Wells PS, Kovacs MJ, Bormanis J, et al. Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low molecular weight heparin. Arch Intern Med 1998; 158: 1809-1812. 0_CHDHJDFJ
- Kovacs MJ, Anderson D, Morrow B, et al. Outpatient treatment of pulmonary embolism with Dalteparin. Thromb Haemost 2000; 83: 209-211. 0_CHDCHHGC
- Douketis JD. Prognosis in pulmonary embolism. Curr Opin Pulm Med 2001; 7: 354-359.
- Simonneau G, Sors H, Charbonnier B, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. N Engl J Med 1997; 337: 663-669. 0_CHDDDBIH
- British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003; 58: 470-483. 0_CHDCGIID