BTS publishes Quality Standards for the outpatient management of Pulmonary Embolism

As part of our Quality Improvement process, BTS develops Quality Standards (QS) to accompany our Guidelines. These Quality Standards are a set of specific and concise statements that describe the standards of care that patients should expect and that should be met by the health service, together with measurable markers of good practice. They are designed to be challenging, yet, achievable, and to drive improvements in care.

Thanks to the availability of direct oral anticoagulants, in the past decade there has been an increase in Trusts embracing the outpatient management of Pulmonary Embolism patients. However, this was also accompanied by greater variability in practice and in a growing number of unvalidated risk assessments. Concerns were raised over the safety of local protocols, given that pulmonary embolism can be fatal.

While guidance for the management of PE was released by NICE as part of its guidelines on the management of thromboembolic diseases in 2012 and 2015, and by the European Society of Cardiology and the American College of Chest Physicians, none of these had recommendations on how to risk-stratify patients for outpatient care, and no clear guidance on their management.

It was against this backdrop, that in 2018 the British Thoracic Society released its first Guideline for the Initial Outpatient Management of Pulmonary Embolism. A guideline developed to establish a standardised approach to identify low-risk Pulmonary Embolism patients that could be safely treated as outpatients, a standardised management plan and also as a guide to identify and manage moderate-risk patients appropriate for early discharge.

The new quality standards released today follow from these guidelines, and are meant to allow healthcare practitioners to base their clinical decisions on the latest evidence and best practice. They provide a set of measures to check the quality and safety of the care they are providing against an agreed and recognised scale.

As well as improving best practice and outcomes for patients, the new quality standards will form the basis of the clinical auditing process for this area, and offer healthcare leaders a way to examine the clinical performance of their organisation. For people with respiratory disease, their families and carers, BTS quality standards such as the one published today enable them to better understand what services they should expect from their health and social care provider.

Dr Robin Condliffe, chair of the Quality Standards group, said:

"It is both mine and the group's hope, that these standards will encourage the implementation and use of a high quality, patient-centred and evidence-based outpatient management pathway in all UK acute hospitals."

The standards, in brief are:

• CT pulmonary angiography (CTPA) should be performed within 24 hours of presentation in patients who are managed via an outpatient pathway and do not have contraindications for contrast imaging.
• All patients with confirmed acute PE or on an outpatient pathway for suspected acute PE should have their clinical risk assessed including the use of a validated risk score (PE severity index (PESI), simplified PESI (s-PESI),Hestia).
• Outpatient management should be offered to all patients with suspected or confirmed acute PE who satisfy clinical risk and exclusion criteria. All patients managed via an outpatient PE pathway should be reviewed by a senior clinical decision-maker prior to going home.
• All patients managed via an outpatient PE pathway should receive verbal and written information containing details of potential complications of the disease process, its treatment and a point of contact.
• Patients 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.

The Quality Standards are also published in BMJ Open Respiratory Research

Dr Condliffe, lead of the Quality Standards group, has provided an interview to Respiratory Futures, where he talks about the rationale behind this new document.