Effective management of acute pulmonary embolism begins with a multidisciplinary approach, according to Teresa L. Carman, MD, from the University Hospital Cleveland Medical Center.
“It has now been a decade since the Surgeon General’s Call to Action on venous thromboembolism. The purpose of the call to action was specifically to raise public awareness,” she said at TCT 2018. “I will tell you we still are not quite there.”
Improvements have been made, but more can still be done to establish and enforce hospital prophylaxis patterns as well as to encourage early adoption of new scientific knowledge. In the past decade, though, there have been many advances in VTE and PE management than in many other arenas, Carman said.
“The incidence of PE seems to be going up, yet case fatality rates are going down. Why is this? It could be better because we’re getting better at diagnosing it. We may have improvements in our initial management. Or, maybe it’s related to the increased use of our adjunctive and advanced therapies. It’s hard to know,” she said.
One way to definitively improve PE management is through the formation of a Pulmonary Embolism Response Team (PERT), according to Carman. The team, she noted, is similar to those programs that already exist for other conditions, including STEMI, in which a multidisciplinary group of the appropriate clinicians needed to treat a patient are activated and mobilized.
The goal, particularly at her own institution composed of 11 hospitals, Carman said, is to increase access to care and manage acute PE early. The hope is to allow systematic evaluation and assessment of these patients, which can vary depending on which specialist sees the patient first. This difference in care, according to Carman, may be a problem.
“We want to be able to use a multidisciplinary approach to manage our high-risk and intermediate-risk patients as aggressively as necessary or as appropriate,” Carman said. “More importantly, we need to have some optimization of our resource utilization. We can’t and shouldn’t lyse all of these patients, and we can’t and shouldn’t put all of these patients in the unit. However, there are certainly patients who are sick enough that they need a higher level of care, and we want to create a pathway to consistent follow-up and take care of these patients long term.”
Different clinicians, she said, may also have different levels of experience with PE. Some clinicians, for example, may encounter these patients less often and therefore may have more difficulty managing a high-risk patient with PE.
“We want to have consistent management. For patients with acute needs, we have to make sure circulation and hemodynamics are well-respected in the first 24 hours. Then, at the 24- to 72-hour mark, we want to make sure they get the appropriate initial therapy because there is an increased risk for recurrence. We also want to risk-stratify them for any additional therapies that may be necessary,” Carman said.
Additionally, for intermediate-risk patients, clinicians must have good planning for anticoagulation as well as a good discharge plan, according to Carman. Understanding the etiology, modifying risk for recurrence and consideration of other factors, such as contraception or need for removal of an inferior vena cava filter, are essential for providing long-term care.
Starting the PERT program
Carman said initiating a PERT program at her institution began with identifying primary stakeholders, including interventional cardiology, vascular medicine and pulmonary medicine specialists.
They then had “soft runs” during the past several months. The soft runs included consultation of one or more PERT members followed by discussion among all involved to ensure the creation of a comprehensive care plan for the patient presenting with PE. Information technology needs, such as a PERT pager, were also addressed so that all PERT members have dial-in meeting access on their phones or computers that includes access to images as well as voice.
After that, all stakeholders are engaged, which include the medical and surgical ICUs, so that clinicians know where to send these patients. Further, not only are clinicians from various specialties alerted, such as cardiothoracic surgeons, interventional radiologists and vascular surgeons, but PERT members identify the need for activation of other resources, including extracorporeal membrane oxygenation or additional therapies such as a right ventricular assist device.
Although they strive to have buy-in from all specialties, Carman said, the pulmonary fellow is the first consult person at her institution because he or she is always in-house, whereas some specialists, such as cardiology, take home call or are seeing patients at other hospitals within the system. The idea behind PERT, she noted, is that members from pulmonary critical care, vascular medicine and interventional cardiology should be available to discuss the patient, see the imaging and weigh in on the care plan. All specialists are then brought in to help formulate a short-term and long-term plan.
When starting the program, Carman said, the plan for PERT was distributed through various communication channels. Eventually, they hope to expand to the community hospitals using the dial-in access, but at present, those patients will likely still need to be triaged, managed and ultimately sent to the main center to be brought into the system.
“PE is too common and these patients are ultimately too high-risk to ignore. Risk stratification can impact your outcomes, and I think it’s important to risk-stratify all these patients. Management strategies are expanding, but with that comes increased costs, and in order to be cost-effective, we have to manage these adjunct therapies in a responsible manner,” Carman said.
“[PERT] brings the stakeholders to the table to create order, help create pathways and provide consistent care to these patients, both in initial management, intermediate management and long-term management, which is ultimately the goal,” she said. – by Melissa Foster
Carman TL. Session I. Acute Pulmonary Embolism. Presented at: TCT Scientific Symposium; Sept. 21-25, 2018; San Diego.
Disclosure: Carman reports no relevant financial disclosures.