The Implementation of a Pulmonary Embolism Response Team in the Management of Pulmonary Embolism

Abstract

Massive and submassive pulmonary embolism (PE) can be life-threatening. Management options include anticoagulation, systemic fibrinolysis, and interventional treatment with catheter-directed or open surgical thrombus removal with or without extracorporeal membrane oxygenation. Currently, most patients with PE, even if they are hemodynamically unstable, are treated with anticoagulation alone. With increasing patient complexity and several therapeutic options, the optimal approach for patients with intermediate- to high-risk PE is not clearly established. The implementation of a clinical pathway executed by a multidisciplinary, rapid response team can optimize risk stratification and expedite management. To this end, the PE response team (PERT) was created at our institution with specialists from vascular surgery, critical care, interventional radiology, emergency medicine, cardiac surgery, and cardiology. The team used current evidence, knowledge, and recommendations as well as institutional experience to reach consensus and to create a risk stratification and treatment algorithm for management of patients with massive and submassive PE. The team is organized as a rapid response team and is activated with a 24-hour telephone number to evaluate and to treat these patients using the algorithm. We review our initial experience with this approach. The records of patients who were treated by the PERT in 2016 (inception late 2015) and 2017 were reviewed (intervention group). The diagnosis codes of these patients were retrieved from the Vizient database, and a retrospective control cohort group was created using these specific diagnoses and a matching set of demographics (age, gender, race), Medicare Severity Diagnosis Related Group, admission severity of illness, and admission risk of mortality. Statistical analysis was performed using the Fisher exact test, the Pearson χ2 statistic, Student t-test, and Cochran-Cox approximation. P < .05 was considered significant. There were 77 patients treated by activation of the PERT pathway; 992 patients were included in the control group, and these patients were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of risk of mortality and severity of illness, and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower intensive care unit stay and overall length of stay. No difference was seen in direct cost between the two groups. The results are summarized in the Table. There was higher utilization of interventional treatment in the PERT group (57% vs 40% for control). In our institution, patients with massive or submassive PE are managed by a dedicated team that implements a clinical algorithm developed by the team. This results in expedited treatment and reduced variation of care. Intensive care unit stay and overall length of stay are reduced by this approach, and the direct cost is not increased despite the use of advanced modalities of treatment. We believe that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved.TableLength of stay, intensive care unit stay, mortality, and cost comparison for pulmonary embolism response team (PERT) and control groupLength of stay, daysIntensive care unit stay, daysDirect cost, $Mortality rate, %ControlPERTControlPERTControlPERTControlPERTMean9.226.316.864.412,219.7016,843.2013.3815.07Standard deviation16.097.449.355.0520,957.6025,242.50Cochran P value.004.006.12.72 Open table in a new tab