The Pulmonary Embolism Response Team: Coming to an ED Near You

The Pulmonary Embolism Response Team: Coming to an ED Near You

By Tim Montrief, MD, MPH, PGY-2; Justin Rafael De la Fuente, MS-2; Jeff Scott, DO, FACEP, EDIC

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 similarly structured 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, 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 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 the use of CDT—a treatment methodology that has demonstrated advantages in alleviating the PE obstruction over heparin alone. [3,10] Greater utilization of CDT initially carried a fear for increased bleeding complications, but MGH demonstrated no significant increase in these events. [10] Similarly, the Cleveland Clinic PERT utilized systemic thrombolysis in 18% of their patients in the first two years of implementation and experienced zero bleeding complications. [3,11] In the absence of clear guidelines for massive and submassive PE, PERT has allowed for safer utilization of advanced treatments, which can maximize patient benefit while also ensuring that minimal risk is involved.

Further work is needed to assess how PERT can be optimized for cost-effectiveness and to minimize mortality, but early results are promising. By utilizing a multi-disciplinary approach to PE care, multiple expert opinions can be consulted in navigating the numerous treatment options for PE, ensuring that the patient’s care is tailored to the best option for them with the least risk. [12]

If you are interested in learning more about PERTs, a good first step is to contact the PERT Consortium at pertconsortium.org. This organization represents a growing number of medical centers dedicated to improving PE care via PERT implementation, and member institutions have experience establishing programs with varying levels of resources in a variety of locations. ■

References

1. Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008;358(10):1037-52.

2. Root CW, Dudzinski DM, Zakhary B, Friedman OA, Sista AK, Horowitz JM. Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT). J Multidiscip Healthc. 2018;11:187-195.

3. Rali PM, Criner GJ. Submassive Pulmonary Embolism. Am J Respir Crit Care Med. 2018;198(5):588-598.

4. Ge Z, Baber U, Claessen BE, et al. The prevalence, predictors and outcomes of guideline-directed medical therapy in patients with acute myocardial infarction undergoing PCI, an analysis from the PRO- METHEUS registry. Catheter Cardiovasc Interv. 2018

5. Kabrhel C. Achieving Multidisciplinary Collaboration for the Creation of a Pulmonary Embolism Response Team: Creating a “Team of Rivals”. Semin Intervent Radiol. 2017;34(1):16-24.

6. Dudzinski DM, Piazza G. Multidisciplinary Pulmonary Embolism Response Teams. Circulation. 2016;133(1):98-103.

7. Pulmonary Embolism Response Team. The University of Texas MD Anderson Cancer Center. Available at: https://www. mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-management/clin-management-pert-web-algorithm.pdf. Accessed Oct. 17, 2018.

8. Rosovsky R, Borges J, Kabrhel C, Rosenfield K. Pulmonary Embolism Response Team: Inpatient Structure, Outpatient Follow-up, and Is It the Current Standard of Care?. Clin Chest Med. 2018;39(3):621- 630.

9. Xenos ES, Davis G, Green A, et al. The Implementation of a Pulmonary Embolism Response Team in the Management of Pulmonary Embolism. Journal of Vascular Surgery. 2018;67(1):e13-e14.

10. Kabrhel C, Rosovsky R, Channick R, et al. A Multidisciplinary Pulmonary Embolism Response Team: Initial 30-Month Experience With a Novel Approach to Delivery of Care to Patients With Submassive and Massive Pulmonary Embolism. Chest. 2016;150(2):384-93.

11. Mahar JH, Haddadin I, Sadana D, et al. A pulmonary embolism response team (PERT) approach: initial experience from the Cleveland Clinic. J Thromb Thrombolysis. 2018;46(2):186-192.

12. Rosenfield K, Rosovsky R. Multidisciplinary Care for Pulmonary Embolism. Advances in Motion. https://advances. massgeneral.org/cardiovascular/article. aspx?id=1007. Published Oct. 24, 2017. Accessed Oct. 26, 2018.