Journal club presentation

1. Predictors of Prolonged Hospital Stay in Patients with
Acute
Pulmonary Thromboembolism
(A Hospital Based Cohort Study)
Presentor- Dr.Tapas Tripathi
Modarator- Dr. Rashika Sah
Journal of The Association of Physicians of India May 2022

2. Introduction
 Pulmonary thromboembolism (PTE) is a relatively common and potentially fatal
medical emergency.
 It is the third most common cardiovascular disease after acute coronary syndrome
and stroke, with an incidence rate of 112 cases per 100,000 in the general population.
 PTE is associated with a wide variety of presenting features, ranging from no
symptoms to sudden death.
 Most Patients with PTE are admitted to hospital for their initial treatment.
 Several factors are believed to influence length of hospital stay in pulmonary embolism
patients, including patient demographics, clinical characteristics, physician resistance,
difficulty in risk stratification, and the type of anticoagulation received.

3.  However, no validated predictive models are available to estimate the
length of hospital stay in pulmonary embolism patients.
 There is very scarce data from the developing countries regarding
pulmonary embolism associated hospitalisations and the factors affecting
the length of hospital stay.
 The aim of this study was to identify factors that are associated with
prolonged hospital stay in patients admitted due to pulmonary embolism.

4. Materials and Methods
 It was a hospital based observational prospective study, conducted at a
leading tertiary care institute in north India.
 Patients were included only if they had confirmed diagnosis of pulmonary
embolism by CT pulmonary angiography.
 Patients with a history of pulmonary embolism prior to present
hospitalisation were excluded from the study.
 The in-patient medical records of all the included patients were reviewed
and the length of hospital stay was calculated for each eligible patient.
 Hospital stay was calculated from the date of admission to the date of
discharge or death.

5.  Based on the PESI score, patients were classified into five different
classes: Class I: PESI Score of ≤65 points, Class II-;66–85 points, Class III:
86–105 points, Class IV: 106–125 point and Class V: >125points.
 Mean length of hospital stay was calculated for this cohort of patients
and patients were later stratified into two cohorts: Shorter Hospital stay
(less than mean i.e., < 10 Days);
 Prolonged Hospital stay (longer than mean i.e., ≥10 Days). t-test was
employed for comparing continuous variables between the two cohorts.
Chi-square test or Fisher’s exact test, whichever appropriate, was applied
for comparing categorical variables.

7. Results
 A total of 150 patients were enrolled during the 4-year study period. Mean
hospital stay for these patients was 10 days.
 67 patients (44.67%) had shorter hospital duration (less than mean duration of
10 days) and 83 patients (55.33%) had prolonged hospital stay (≥10 days).
 Male sex and rural background of patients did not predict prolonged hospital
stay.
 The most common underlying risk factors in our patients with pulmonary
thromboembolism were immobilization (defined as bed rest for more than 3
days), chronic lung disease, malignancy, history of trauma to lower extremity
and pelvis within preceding three months, recent surgery and previous history
of stroke.

8.  Tachycardia (defined as heart rate of 100 per minute or more), tachypnea
(defined as respiratory rate of 20 per minute or greater), hypotension
(defined as blood pressure of less than 90/60 mm Hg for more than 15
minutes) and decreased level of consciousness (defined as Glassgow Coma
Scale score of less than 15) at presentation were found to be significantly
more prevalent in the cohort of patients with prolonged hospital stay.
 Different lab parameters were compared in the two cohorts of patients
and it was found that total leucocyte count (TLC) of greater than
11,000/ul, spo2 less than 90%, and pCo2 of less than 30 mm Hg were
more common in patients with prolonged stay. elevated troponin levels
(measured qualitatively by rapid card tests) were significantly more
common in patients with prolonged hospital stay.

9.  Among the ECG findings, presence of sinus tachycardia, S1Q3T3, Rightaxis
deviation (RAD) and right bundle branch block (RBBB) were significantlyassociated
with prolonged hospital stay.
 Similarly, presence of dilated RA/ RV, RV hypokinesia and pulmonary hypertension
(PAH) were more likely present in prolonged hospital stay.
 Mean d dimer was calculated for the patients with shorter hospital stay and
prolonged hospital stay.
 The difference between the two cohorts was not statistically significant. Use of
thrombolytic agents and presence of complications were associated
withprolonged hospital stay.

11.  The mean duration of hospital stay varied significantly with the PESI class,
with patients belonging to class I having a mean stay of 6.9 days (SD=5.78
days) and patients belonging to class V having a mean of 17.1 days (SD=6.13
days)
 150 patients were included in the study with 67 patients (44.67%) having
shorter hospital stay (<10 days) and 83 patients (55.33%) having
prolongedhospital stay (≥10 days). On multivariate regression analysis,
parameters that were found to be statistically significant were hypotension
at presentation, decreased level of consciousness, pco2 < 30 mmHg,
presence of S1Q3T3 pattern on electrocardiogram (ECG) and high risk PESI
(class III-V).

14. Disscusion
 Our study shows that hemodynamic instability and decreased level of
consciousness at presentation is associated with prolonged hospital stay in
patients with pulmonary embolism.
 Our study shows that the proportion of patients with an elevated leucocyte
counts, pco2 less than 30, spo2 less than 90% and elevated cardiac
troponins was significantly higher in patient cohort with prolonged hospital
stay.
 Presence of low Pco2 independently predicted a prolonged hospital stay.
 Though the exact reason for this observation could not be ascertained, it
could be partly because of increased respiratory distress in these patients
with subsequent prolonged observation period.

15.  Our study shows that the proportionof patients with an elevated
leucocyte counts, pco2 less than 30, spo2 less than 90% and elevated
cardiac troponins was significantly higher in patient cohort with prolonged
hospital stay.
 Presence of low Pco2 independently predicted a prolonged hospital stay.
ECG signs that are reported as good predictors of a negative outcome
included S1Q3T3, complete right bundle branch block, T-wave inversion,
right axis deviation, and atrial fibrillation.
 We found in our study that S1Q3T3, Right axis deviation and right bundle
branch was significantly present more in patients with a prolonged
hospital stay than patients with a shorter hospital stay.

16.  PESI) is the most extensively validated tool devised to predict mortality in
patients with PE and identify low risk patients who may be candidates for
outpatient treatment.
 We aimed to analyse the usefulness of PESI score and PESI class in
predicting the duration of hospital stay in patients with pulmonary
embolism.
 Our study found that higher the PESI class, more is the duration of hospital
stay. Also, a PESI score of >95 points predicted a prolonged hospital stay
with a sensitivity of 81.9% and a specificity of 50%.

17. Limitations
 There are certain limitations inour study. First, the healthcare setup in which
study was conducted is not universal and the results can’t be generalised.
 Secondly, attitude oftreating physicians varies widely with regards to ideal
time to discharge the patients with pulmonary thromboembolism and this
could be one confounding factor.
 Finally, many patients had delay in discharge because of use of
conventional oral anticoagulants, but we had no data regarding the delay
caused by getting INR in the therapeutic range.

18. Conclusion
 PESI class can be effectively used to predict prolonged hospital stay in
patients with pulmonary embolism. Patients with hypotension at
presentation, decreased level of consciousness, pco2 less than 30 mmHg,
and S1Q3T3 on ECG are more likely to have prolonged hospital stay in our
healthcare setup.
 The findings from this study may help clinicians to take decision
prospectively about duration of hospital stay for effective health care
utilisation in patients with pulmonary embolism.

19. TAKE HOME MESSAGE
Patients with severe pulmonary embolism
(hypotension at presentation, decreased level of
consciousness, pco2 less than 30 mmHg, and
S1Q3T3 on ECG) are more likely to have
prolonged hospital stay.

20. Thank You