Cleveland Clinic’s Pulmonary Embolism Response Team
Effective PERTs reduce mortality, and the growth of these teams is a good example of how multidisciplinary, coordinated, team-based care can work in a complex setting.
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Each year 300,000 to 600,000 cases of pulmonary embolism (PE) occur in the U.S. Ten to 30 percent of the time, the patient dies within one month. Lack of a standardized approach to treating PE — especially submassive PE — may influence this high mortality rate.
Current guidelines do not clearly outline treatment for acute PE, particularly massive and submassive. Decision-making lacks consistency, and procedures performed vary significantly by medical service, location and size.
To address this problem, we assembled a multidisciplinary pulmonary embolism response team (PERT) to provide rapid evaluation, risk stratification and management recommendations for PE patients.
Our team, created in 2014, consists of caregivers representing pulmonary and critical care medicine, vascular medicine, interventional radiology and cardiology, cardiothoracic surgery, hematology and pharmacy. This multidisciplinary group, available around the clock, allows for a diversity of viewpoints when evaluating patients and their particular situation with an eye toward rapid initiation of optimal treatment.
When a patient is admitted with PE, we follow an algorithm to assess their risk and determine whether to activate the team. Patients judged as low-risk — small clots, normal blood pressure and no evidence of right ventricular strain — are started on anticoagulants. Those deemed high-risk — hypotension, massive PE — are treated with systemic lysis or embolectomy with or without IVC filter. Those with submassive PE present the biggest treatment dilemma (Figure). Massive and especially submassive PE benefit the most from PERT activation.
A dedicated pager number notifies team members of an online meeting (via email or instant messaging platform) followed by a bedside meeting with PERT members joining in person or virtually. The team devises a recommended management plan within 180 minutes of PERT activation. The team draws on resources in the OR, the cardiac and interventional radiology labs, and vascular the ultrasonography suite for targeted implementation. If any of these resources are deemed necessary, the PERT is able to mobilize the appropriate staff to facilitate expedited intervention.
Based on a retrospective chart review from October 2014 through August 2016 presented at the CHEST 2016 annual meeting, our PERT has been activated for 134 patients, 112 of whom were found to have PEs. The number of low-risk, submassive and massive PEs were 14 (12 percent), 76 (68 percent) and 22 (20 percent), respectively. Just over half, 55 percent (60 patients), were treated with anticoagulation therapy alone. IVC filters were placed in 32 patients (29 percent). Twenty-one patients received systemic thrombolysis, fourteen received catheter-directed thrombolysis, three received a suction thrombectomy, and four received a surgical embolectomy.
For this time period, the 30-day all-cause mortality rate was 9 percent; deaths occurred in six patients with massive PEs, three patients with submassive PEs and one patient with a low-risk PE. Six of the patients who died had been treated with anticoagulation, two had received catheter-directed thrombolysis and one had received a full dose of systemic thrombolysis. Only four deaths (3.6 percent) were related to PE. The remaining six patients died under terminal hospice care.
Bleeding complications occurred in 14 patients (12.5 percent), eleven of whom were treated with anticoagulation alone and three of whom underwent catheter-directed thrombolysis. There were no major bleeding complications in patients treated with systemic thrombolysis. Before PERT, the major bleeding rate in patients treated with systemic thrombolysis for PE in our institution was 45 percent.
We expect the number of PERTs around the country to grow in the next five years. This will give PE patients access to advanced beneficial therapies such as systemic thrombolysis, catheter-directed interventions and surgical embolectomies. We are already seeing evidence that the number of these procedures is rising and that safety is improved. Effective PERTs reduce mortality, and the growth of these teams is a good example of how multidisciplinary, coordinated, team-based care can work in a complex setting.
Dr. Heresi is Medical Director of the Pulmonary Thromboendarterectomy Program in the Department of Pulmonary and Critical Care Medicine.