In this episode, I’ll discuss pulmonary embolism response teams.
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Acute pulmonary embolism (PE) is associated with in-hospital mortality rates of 1.6 to 24%, depending on the severity of the disease.
About 5% of patients with acute PE present as hemodynamically unstable with massive PE. The remaining 95% of patients with PE represent a diverse patient population. About a third of this group represents patients with stable blood pressure and a small PE that can clearly be treated with anticoagulation alone.
But the majority of patients with PE fall into an intermediate risk group. These patients are often said to have “submassive PE.” They are a heterogeneous group. They may have a stable blood pressure but a very large clot burden, or a borderline blood pressure and evidence of right ventricular dysfunction.
There exists a myriad of treatment possibilities provided by numerous medical subspecialties for patients in the intermediate risk group of submassive PE. The treatments include inferior vena cava filter placement, catheter-directed thrombolytic therapy, embolectomy, and thrombus fragmentation. In an attempt to give individual patients the most appropriate treatment, the input of many specialties must be considered. This is a time-consuming process, however, and the potential exists for up to 5% of patients with submassive PE to clinically deteriorate while the best course of treatment is being deliberated.
The pulmonary embolism response team
A solution to rapidly bring together the multiple specialties to identify the best course of treatment for a given patient is the pulmonary embolism response team (PERT).
Massachusetts General Hospital (MGH) is well-known for publishing the formation and results of its PERT. The team was modeled after “heart teams” in heart transplantation and congenital heart disease, and tumor boards in oncology.
The goal is to rapidly achieve cross-speciality collaboration to make the best decision for patients.
On the need for a PERT, the team at MGH has stated:
…these patients represent a point of clinical equipoise for which no single clinical trial or group of clinical trials is likely to provide the answer. Instead, a careful, individualized risk-benefit assessment is required, with experts weighing available data in terms of study methodology and data quality, measured end points, and generalizability to the current patient.
MGH’s PERT
PERT is staffed by select experts from Cardiovascular Medicine, Interventional Cardiology, Vascular Medicine, Cardiothoracic Surgery, Echocardiography, Emergency Medicine, Hematology, Pulmonary and Critical Care Medicine, and Radiology. Similar to the rapid response system, the PERT is activated by a pager system. A single physician from the PERT responds, evaluates the patient and schedules a web-based video conference within 90 minutes with the rest of the team.
The Web-based video conference involves discussion of the patient’s specific presentation, thromboembolic risk factors, comorbidities, and goals and preferences, and concludes with a consensus decision on treatment strategy.
…for the first 350 MGH PERT patients, 9.6% underwent advanced percutaneous therapies and 4.1% underwent surgical pulmonary embolectomy, whereas 62% received anticoagulation alone, 21% received an inferior vena cava filter, and 3% received systemic fibrinolysis.
Pharmacist’s role
Whether your hospital has or is thinking of forming a pulmonary embolism response team, I think a pharmacist should be involved. The obvious benefit is that in the case of thrombolytic therapy, the pharmacist will be notified the moment the clinical decision is made, reducing the time it will take to provide the thrombolytic.
Also, invariably patients with submassive PE have complex scenarios relating to anticoagulation and bleeding risk. A pharmacist’s input on the onset, duration, contraindications, and dosing concerns for the numerous treatments available for PE can be of tremendous value to the rest of the team as patient management decisions are being made.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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