Your trust wants to expand same-day emergency care to reduce admissions. You have been asked to develop a pathway for one condition. How would you approach it?

Question

You are the acute medicine registrar. The trust has identified low-risk pulmonary embolism as a candidate for an ambulatory pathway. Admissions for PE currently average 3.2 days.

Accepted Answer

Low-risk PE is a good choice because there is a strong evidence base and validated risk stratification, so I would start there. The clinical core of the pathway is deciding who is genuinely low risk: I would use a validated tool such as sPESI or the Hestia criteria, and add the practical exclusions that those tools do not capture — right ventricular strain on CT or echocardiography, a raised troponin, significant hypoxia, active bleeding or a high bleeding risk, severe renal impairment, pregnancy, significant pain requiring parenteral analgesia, and social circumstances that make home management unsafe such as living alone with no telephone. I would write those exclusions explicitly into a standard operating procedure rather than leaving them to judgement. The part most pathways get wrong is the edges, so I would design the out-of-hours entry route first: a patient diagnosed at 22:00 on a Saturday needs the same pathway as one seen in a Tuesday clinic, which means a clear decision-maker, access to the anticoagulant, and a booked follow-up. Safety-netting would be explicit — written information, a named contact number, a defined route back into the unit without going through the emergency department, and a follow-up appointment at 48 hours and then in the VTE clinic. I would engage the emergency department, radiology, pharmacy, the ambulatory nursing team and primary care from the outset, and get consultant and governance sign-off before going live. I would pilot in small PDSA cycles rather than launching trust-wide. My outcome measure would be the proportion of PE presentations managed ambulatorily, plotted on a run chart; process measures would include the proportion risk-stratified with a documented tool and the proportion with a booked follow-up; and my balancing measures would be readmission at 7 and 30 days, major bleeding, and mortality, because a pathway that reduces admissions while causing harm has failed.

Developing a Same-Day Emergency Care Pathway

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