Improving the care of patients discharged following a pulmonary embolism, in line with NICE Guidelines (NG158)

Pulmonary embolism (PE) is an acute and potentially fatal condition in which embolic material, typically a thrombus originating from one of the deep veins of the legs or pelvis, blocks one or more pulmonary arteries, causing reduced blood flow and increased pressure to the right cardiac ventricle. The incidence of PE increases with age. Mortality rates can be as high as 25% if untreated however, with anticoagulant therapy, this rate decreases to about 2–8% in the 3 months following diagnosis. The benefit of early anticoagulation to improve mortality and decrease recurrent thromboembolism is well proven. For PE secondary to reversible risk factors, 3 months treatment with anticoagulants is recommended.

It is important that patients are followed up closely after experiencing a PE as they have an increased risk of developing major bleeding from anticoagulant therapy, recurrent venous thromboembolism (VTE), arterial cardiovascular diseases, or chronic functional limitations.

A study by Konstantinides, et al (2014) found that patterns of patient follow up post PE differ greatly and firm evidence to provide guidance is lacking. Historically, patients with PE have been treated within the hospital environment, however increasingly, patients are being discharged and treated as outpatients if they are haemodynamically stable. Treatment as an out-patient avoids the risk of hospital acquired morbidities and the stress and anxiety associated with being treated in hospital. This is also likely to reduce costs to the health service.

The NICE guidance NG158 states in sections 1.2 and 1.5 that patients should be discharged with adequate monitoring of anticoagulant treatment and that the patient is provided with sufficient information and education. The purpose of this work was to determine if patients are provided with this information upon discharge and to determine how this service can be improved. Key points were that important information was missed and improvements need to be made.

Symptomatic venous thromboembolism occurs in 1–2 per 1,000 adults each year, with about a third presenting with PE (Douma, Kamphuisen & Buller, 2010). Mortality rates can be as high as 25% if untreated (Douma, et al, 2010) however, with anticoagulant therapy, this rate decreases to about 2–8% in the 3 months following diagnosis. The benefit of early anticoagulation to improve mortality and decrease recurrent thromboembolism is well proven (Smith, Geske, Maguire, et al, 2010). For intermediate and low risk patients with PE, guidelines recommend to start administration of anticoagulants early (NICE, 2020). Vitamin K antagonists (such as Warfarin) can be started as early as the first or second day; newer Direct Oral Anticoagulants (DOAC), such as apixaban, rivaroxaban, dabigatran and  edoxaban, are now commonly given to patients and have overcome some of the limitations of standard therapy such as the need for injections or regular monitoring (Büller, Prins & Lensin, et al, 2012).

Previously patients were discharged and seen in three months by the respiratory consultant. However, this study has shown that it is important that patients are followed up closely after experiencing a PE as they have an increased risk of developing major bleeding from anticoagulant therapy, recurrent venous thromboembolism (VTE), arterial cardiovascular diseases, or chronic functional limitations. Historically, patients with PE have been treated within the hospital environment, however increasingly, patients are being discharged and treated as outpatients if they are haemodynamically stable (Kearon, Comerota, Prandoni, et al, 2012). Treatment as an out-patient avoids the risk of hospital acquired morbidities and the stress and anxiety associated with being treated in hospital. This is also likely to reduce costs to the health service (NICE Guidance, NG158, 2020).

Recommendations in section 1.5 of NICE Guidance NG158 state that patients should be discharged with adequate monitoring of anticoagulant treatment and that the patient is provided with:

• An anticoagulant information booklet.
• An anticoagulant alert card.
• Verbal and written information on oral anticoagulation treatment, including:
• How to take and their duration of treatment.
• Possible adverse effects and what to do if these occur.
• The effects of other medications, foods, and alcohol on oral anticoagulation treatment.
• When and how to seek medical help.

 The purpose of this work was to determine if patients are provided with this information upon discharge and to determine how this service can be improved.

The British Thoracic Society Guidelines (2018) state that patients should have a formal review (telephone/face to face) during the first week after discharge to ensure therapeutic compliance along with the absence of complications. Hospitals should have local protocols and pathways in place for follow-up of all PE patients. This should include assessment of ongoing symptoms and consideration of optimal duration of anticoagulation (Howard, Barden, Condliffe, et al, 2018).

Discussion was held between the Respiratory Consultant, Acute Medicine Consultant, Haematology Consultant, Pharmacist and Anticoagulation Staff to improve the quality of service provided to patients discharged on anticoagulation following a PE. Previously, patients would be counselled regarding their treatment on the ward by medics or pharmacists prior to discharge and followed up within 2-3 months usually by their respiratory consultant or haematology consultant if small segmental or subsegmental PE. It was decided that anticoagulation nurse specialists would contact patients, within a week of discharge, to determine their understanding of their medication and offer support if needed. A protocol was created outlining important aspects of care (Appendix 1). Patients would be contacted and questions were asked regarding their medication, discharge and information received.

It can be seen that this trial was of vital importance to patient satisfaction and patient outcomes. Previously there was a mixed approach to PE follow up care. Large/bilateral PEs were seen under respiratory and at 3 months, small segmental and subsegmental unprovoked PEs were seen at 3 months by the haematologists and there was no follow up for small provoked clots.

This is to be changed to a more efficient service; signposted by a PE pathway and electronic referral system and designed to be in line with all guidelines. This should start with better patient information upon discharge, such as suitable leaflets provided to patients and DVDs being more prevalent on the ward. A new DVD has been commissioned with updated patient information and will rolled out to wards upon completion. This will provide patient with up to date information and ensure that patients are counselled in a more standard fashion. 

Safer prescribing should follow with pharmacy input and nurse specialists will follow up patients with a one-week phone call to pick up any problems and allay any concerns noted in this pilot study. 

From the results of nurses’ discussions with patients it can be seen that the majority of patients saw improvement in their symptoms and showed little evidence of bleeding or side effects. Most patients were aware of their referrals to the service and of their dose reduction date and where to obtain support regarding repeat prescriptions. However, there were some areas of the process that need to be improved. It was noted that 20% of patients were not given advice on what to do if their condition deteriorates.

This information is of vital importance if their symptoms worsen (Gudula, Boon, Bogaard & Klok, 2020). PE mortality rates are known to increase when not treated correctly (Ozsu, Oztuna, & Bulbl, 2011) and delays in treatment should be avoided (Calwin Davidsing, et al, 2014).

Furthermore 74% of patients were not shown the DVD provided to wards counselling patients regarding their commencement of anticoagulants. 68% of patients state they were spoken to by a member of staff regarding commencement of their medication but over a quarter or patients were not counselled. NICE Guidelines NG158  (2020) state for the initial outpatient management of pulmonary embolism recommend that patients with confirmed PE should be provided with verbal and written information on the signs and symptoms of recurrence, major bleeding and additional complications. Hospitals should also provide an appropriate point of contact in the event of complications or concerns and provide written patient information and education is integral to outpatient PE pathways. Succinct written information should be provided to patients on discharge (Howard, Barden, Condliffe, et al, 2018).

The results of this study, however, note that patients often weren’t provided with this information. In terms of specific written information on discharge over half of patients were not provided with a leaflet regarding their anticoagulation and 47% were not provided with an alert card to alert others to their new medication. This standard seems to fluctuate and needs to be addressed on future discharges. To improve these issues, following discussion with patients, when nurses determined patients had not received relevant information, this was immediately sent to the patient. It can be seen that this safety netting facility provided by the specialist nurse team is vital in improving patient understanding and safety.

NICE guidance NG158 states the importance of ensuring the importance of ensuring patients have direct contact details of healthcare professionals with an expertise in thrombosis who can discuss any new symptoms or concerns. Furthermore, the British Thoracic Society Guidelines (2018) support this statement and recommend that patients should have a formal review (telephone/face to face) at least once during the first week after discharge to ensure compliance and to check for complications. Trusts should have local protocols in place for follow-up of all PE patients. This should include assessment of ongoing symptoms and consideration of duration of anticoagulation (Howard, et al, 2018).

Following the results of this work, a service was established within the trust to ensure that this follow up was done in a timely manner to improve patient safety and experience.Patients responses were overwhelmingly positive when asked if this change improved their satisfaction with their care. Patients were grateful to have the opportunity to discuss their concerns at a time when their illness had become clearer to them and appreciated the safety net of knowing they had a staff member to contact if they had any further concerns. Patient safety is also likely to have been improved as many times staff discussed with patients issues that may have been missed such as the correct time to take medication, the importance of ensuring a repeat prescription was established and the sharing of information regarding their worsening condition. Patients commented that they found this reassuring  and very helpful.

This service was initiated by three nurse specialists and upon completion of this study has been implemented within the trust and the responsibility shared throughout the team to ensure more patients are contacted in a timely manner. This will be followed up with a 3-month telephone follow up with the respiratory consultant to look for further complications, to ensure no unidentified triggers and to plan the long-term anticoagulation or to stop safely if PE is deemed as provoked.

As a guide to other areas, the initial backlog of cases to audit and contact was a big job for 3 nurses and if implementing this I would increase the number of nurses involved in the beginning to ensure increased output.

The results of this pilot study show that patients overwhelmingly reported increased peace of mind following discussions with nurse specialists and were grateful for the chance to discuss their treatment at a date following their discharge. The need for this service to be continued is supported by NICE guidance NG158 and can ensure that patients are provided with the best care possible in the future. This service is likely to decrease the number of patients readmitted and developing issues with their anticoagulation that would have otherwise gone unnoticed.