The Pulmonary Embolism Response Team COMING TO AN ED NEAR YOU
Tim Montrief, MD, MPH, PGY-2
Introduction Pulmonary embolus (PE) represents a rapidly occurring and potentially fatal condition that remains challenging to diagnose and manage. A patient with a PE can present in any clinical setting, so physicians from the ED to hospital wards must be prepared to face this disease. Although clearer guidelines exist for the management of low-risk PE, the situation can quickly grow more complex in patients with massive and submassive PE.1,2 In addition to anticoagulants, a number of more complex interventions exist, including systemic fibrinolysis, catheter-directed therapies and surgical embolectomy.3 Each management option comes with its own risks and benefits that can be difficult to tailor to the patient, and if a physician decides to pursue one of these therapies, specialists must be consulted. A wide variety of specialties exist for higher-risk PE consultation— including hematology, vascular surgery and interventional radiology—and each one may offer a unique perspective on how to approach the case. Challenges in management have prompted medical centers across the country to develop a multi-disciplinary approach to the PE, known as the PE Response Team (PERT).
Basis of the PERT The PERT is based on other similarlystructured response teams that play important roles in the hospital setting. Code ST-elevation myocardial infarction (STEMI) teams have been pivotal in reducing the mortality associated with MI, due in part to their ability to mobilize the resources required for rapid intervention.4,5 PERTs aim to do the same by ensuring that if the patient is a good candidate for surgical or catheter-based intervention, the necessary steps are taken to ensure that intervention occurs as quickly as possible.6 Additionally, PERTs utilize the multi-disciplinary aspect of trauma teams, 32
Justin Rafael De la Fuente, MS-2
which assemble emergency physicians, trauma surgeons, orthopedic surgeons and more in order to provide the best possible care for the patient.5 The PERT similarly brings together experts in different specialties to ensure that the patient receives the best possible intervention for their PE.
PERT Structure Massachusetts General Hospital (MGH) was the first institution to successfully implement a PERT, providing a framework for the team’s structure. There, it is comprised of experts in interventional cardiology, vascular medicine, cardiothoracic surgery, echocardiography, emergency medicine, hematology, pulmonology, critical care medicine and radiology.6 Activation of the PERT at MGH is available to any clinician who may encounter submassive or massive PE. Upon doing so, an on-call physician on the team is dispatched to provide a quick patient evaluation. After review of patient data, the referring physician and the PERT specialists have an online meeting to discuss the case, allowing the team of up to 15 physicians to devise a consensus treatment strategy that includes insight from multiple specialties. Once a plan is developed, necessary resources are mobilized, which may include organizing an urgent angiography suite or contacting the cardiac surgery team. Ideally this evaluation and meeting occur within a span of 90 minutes post-PERT activation.6 The PERT concept has led to the development of similar teams in medical centers across the country.6 The core concept of the PERT remains the same: to provide rapid, multi-disciplinary insight into management of PE. Some hospitals have gone further and developed algorithms for PE management that include the PERT. For example, at the University of Texas MD Anderson Cancer Center, the PERT can EMPULSE WINTER 2019
Jeff Scott, DO, FACEP, EDIC
be activated for patients with potential intermediate- to high-risk PE. If anticoagulants are not contraindicated, therapy should include IV unfractionated heparin prior to the PERT meeting, and data collected should include BNP, troponin, 2D-echo, type and screen, EKG and venous Doppler ultrasound of the lower extremities. With that information and a PERT first responder assessment, the patient is categorized, and if they remain high- to high-intermediate-risk, the PERT has a virtual meeting to consider more advanced intervention, including mechanical thrombectomy, low dose catheterdirected thrombolysis (CDT), or placement of an IVC filter.7 In addition to providing multi-disciplinary emergency care in the hospital, PERTs may also include a system of outpatient specialist care after discharge. This allows for expedited specialist follow-up, which is beneficial if the patient is developing long-term complications associated with PE, such as chronic thrombotic pulmonary hypertension. If the physician who discovered such a condition was a pulmonologist at a PERT specialist follow-up visit as opposed to the patient’s primary care physician, action can be taken immediately without having to arrange other consultations. This additional care allows for further testing that may elucidate potential cause of the PE, such as occult malignancy. By evaluating for and potentially treating such conditions, the PERT follow-up model can help prevent future episodes of recurrent PE.8
Implementation Outcomes Since the development of the first PERT at MGH, data suggests that the multi-disciplinary approach has key benefits in PE care. At the University of Kentucky, PERT implementation significantly shortened length of stay, both overall and within the ICU.9 Additionally at MGH, there was a noted increase in
