Discharge Criteria for Deep Vein Thrombosis (DVT)
Stable patients with DVT who meet specific clinical and social criteria can be safely discharged for outpatient management with low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs), provided they have no hemodynamic instability, adequate renal function, low bleeding risk, and reliable follow-up arrangements. 1
Mandatory Exclusion Criteria for Outpatient Discharge
Patients must NOT have any of the following to qualify for discharge 1:
- Hemodynamic instability (systolic blood pressure <100 mm Hg with heart rate >100 bpm) 1
- Need for thrombolysis or embolectomy 1
- Active bleeding or high bleeding risk, including:
- Severe renal impairment (creatinine clearance <30 mL/min) 1
- Severe liver impairment 1
- Pregnancy 1
- History of heparin-induced thrombocytopenia 1
- Oxygen requirement >24 hours to maintain saturation >90% 1
- Severe pain requiring intravenous opioid analgesia >24 hours 1
- PE diagnosed during existing anticoagulant treatment 1
Additional Clinical Requirements for Safe Discharge
Beyond exclusion criteria, patients must meet these positive requirements 1:
- Hemodynamically stable with adequate oxygen saturation on room air 1
- No threatened venous gangrene or extensive iliofemoral DVT requiring mechanical or pharmacologic thrombolytic therapy 1
- Strong social support and reliable access to medical care 1
- Good adherence to medically recommended treatment 1
- No medical or social reasons requiring hospitalization >24 hours 1
Required Outpatient Follow-Up Structure
Safe outpatient management requires established support systems 1:
- 24-hour emergency contact number for patients to report complications 1
- Telephone follow-up within 1-2 days of discharge 1
- Clinical review within 7-10 days of discharge 1
- Written instructions regarding warning signs requiring immediate emergency department return 1
- Anticoagulation management plan through primary care physician or dedicated anticoagulation clinic 1
Anticoagulation Requirements at Discharge
Patients must be initiated on appropriate anticoagulation before discharge 1, 2:
- LMWH is preferred over unfractionated heparin for outpatient DVT treatment 1
- DOACs are acceptable alternatives: Rivaroxaban 15 mg twice daily with food for 21 days, then 20 mg once daily 2
- No laboratory monitoring required for LMWH or DOACs in most patients 1
- Warfarin requires overlap with parenteral anticoagulation for at least 4-5 days until INR 2.0-3.0 for 24 hours 3, 4
Special Populations Requiring Inpatient Management
The following patient groups should NOT be discharged 1:
- Concomitant pulmonary embolism with any high-risk features (though highly selected stable PE patients may qualify for outpatient management using simplified PESI score = 0) 1
- Active malignancy (may require extended LMWH rather than warfarin) 1
- Pregnant patients (require LMWH, not warfarin or DOACs) 1
- Morbid obesity (weight >150 kg) 1
- Barriers to treatment adherence or follow-up 1
Common Pitfalls to Avoid
- Do not discharge patients based solely on absence of symptoms, as approximately one-third of DVT patients are asymptomatic 5
- Do not overlook concomitant pulmonary embolism, as above-knee DVT carries increased PE risk 5
- Do not discharge without confirming adequate renal function, as LMWH and some DOACs require dose adjustment or are contraindicated in severe renal impairment 1
- Do not assume all distal (calf) DVTs are low-risk, as approximately one-sixth can extend proximally 5
- Do not discharge without baseline platelet count, as heparin-induced thrombocytopenia monitoring requires baseline values 1