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2019 Pulmonary Embolism Response Team (PERT) Guidelines

Doctor viewing a chest Xray

Contemporary Treatment for Pulmonary Embolism

The recent European Society of Cardiology (ESC) and European Respiratory Society (ERS) Joint release of the Diagnosis and Management of Acute Pulmonary Embolism Guidelines (2019) highlight a number of changes in class level recommendations as compared to the 2014 version, as well as new guideline recommendations.

Among these, a Class IIa recommendation for multidisciplinary management of patients means that awareness of the emerging trends in PE management is crucial. Phillip Green, MD (Columbia University Medical Center) provides an in-depth analysis of Pulmonary Embolus Response Team (PERT) protocols in Contemporary Treatment for Pulmonary Embolism.

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Contemporary Management of Pulmonary Embolism: The Emergence of PERT Teams

Faculty: Philip Green, MD

Learning Objectives

By the end of this activity, you should be able to:

  1. List the specialties that may be involved in the care of a patient with acute pulmonary embolism
  2. Contrast PERT protocols for the treatment of high, low, and intermediate-risk pulmonary embolism
  3. Describe the benefits of a PERT approach for the patients with acute pulmonary embolism, and
  4. Describe challenges associated with instituting PERT approach to the patients with acute pulmonary
    embolism.

Knowledge Check Question

Pulmonary Embolism Response Teams aim to:

A. provide interdisciplinary care for severe pulmonary embolism
B. provide rapid clinical assessment and triage for patients with severe pulmonary embolism
C. improve quality of care, research, and education through the PERT Consortium
D. all of the above

Specialties Involved in Care of Pulmonary Embolism Patient

Pulmonary embolism is characterized by multidisciplinary care. Taking care of a pulmonary embolism patient involves hematology, cardiac surgery, interventional cardiology, pulmonary critical care, echocardiography, radiology, and vascular medicine as well as the multiplicity of other specialties.

We'll focus briefly here on the role and rationale for Pulmonary Embolism Response Teams in taking care of patients for acute pulmonary embolism. We know there's a treatment gap in pulmonary embolism care. Less than 5% of patients with pulmonary embolism receive advanced therapy for pulmonary embolism including those with clear indications like hypotension, right ventricular dysfunction, and positive biomarkers.

Many more patients are eligible for these advanced therapies that actually receive them. Why?

Is it failure to recognize potential benefits and integrate data in real-time? Is it fear of complications related to advanced therapies?

There is an inability to respond rapidly to patients with acute severe pulmonary embolism related to system issues, and there can be paralysis in decision-making. There are so many options and so many people involved potentially that a decision is not made in a timely manner or even at all.

Pulmonary Embolism Response Teams (PERT)

Pulmonary Embolism Response Teams or PERT have a mission to advance the diagnosis, treatment, and outcomes in patients with severe pulmonary embolism.

Their goal is to improve patient outcomes using a collaborative, multidisciplinary, team-based, urgent consult to treat massive and submassive pulmonary embolism.

Their functionality is modeled on rapid response concepts with multidisciplinary team of experts convene via electronic or sometimes in-person meetings, and their job is to evaluate and offer a full range of available treatments selected for the patient with pulmonary embolism.

Treatment Gap in Pulmonary Embolism

The previous paradigm for treatment of patients with severe pulmonary embolism was chaos.

Whether it was an in-patient unit or a referring hospital that identified a patient with a severe pulmonary embolism, someone who identified the pulmonary embolism had to think what was the best option for this patient and then call that particular practitioner.

So, if they thought surgery was the most appropriate therapy, they might call a surgeon who would then say, "You know, this patient isn't an ideal surgical candidate. Maybe consider catheter-directed therapy," and then it would be back for the primary team to call a catheter-directed therapy person like an interventional cardiologist or an interventional radiologist who would then say, "This patient may or may not be a candidate for catheter-directed therapy. Why don't you call intensive care, get the patient to the MICU, and we'll consider catheter-directed therapy?"

Obviously, this is not organized, not streamlined, and not coordinated, and therefore chaotic, and it's understandable why patients wouldn't necessarily get the therapy that they needed.

Pulmonary Embolism Response Team

PERT teams represent an idealized paradigm where an in-patient unit or a referring hospital identifies a severe pulmonary embolism. They activate the PERT team and then the PERT team takes responsibility to convene an interdisciplinary meeting, come to a decision, identify a disposition and treatment plan, and circle back to the primary team to actually help them institute the plan in a timely fashion as necessary for the patient.

When PERT teams were pioneered in Massachusetts General Hospital and this group has studied PERT, it has been shown that PERT teams actually improve efficiency for patients with pulmonary embolism and optimize the use of innovative, cutting-edge therapies.

Why Do We Need a PERT Team?

So, PERT really is a multidisciplinary collaboration at our institution, spearheaded by vascular medicine and intervention but including all the disciplinaries involved in PERT.

PERT has an important role in assessing emerging and adjunctive technologies in pulmonary embolism. What better circumstance to implement newly approved or even experimental technologies for pulmonary embolism that, in the context of an interdisciplinary group of people, focus on pulmonary embolism?

These therapies can be aspiration technologies like Inari FlowTriever or Penumbra thrombus aspiration, ECMO systems of care to hemodynamically support the patient as a bridge to therapy, or even novel anticoagulants or systems to improve compliance.

One of the advantages of the PERT Consortium is the PERT database, which is a web-based HIPAA-compliant, research, data entry form which has up to 347 variables the last time we checked designed for prospective data entry and is scalable both to increase the number of forms but also readily deployable at multiple institutions as the consortium expands. The idea is to leverage the fact that many PERT teams and many institutions are delivering cutting-edge care.

However, the volume at each institution may not be enough to study it. However, with strength and numbers, we may be able to derive more important clinical inferences in a prospective way.

You see here a skeleton sketch of PERT centers every year. This map of PERT centers increases as PERT continues to grow. Challenges associated with instituting PERT teams include appropriate reimbursements.

How is this PERT meeting reimbursed?

Can every participant in a PERT meeting be financially reimbursed for their contribution?

In addition, certain turf wars and traditional barriers do need to be broken down but successful PERT teams do require a uniform recognition that the patients do better when the disciplines work together to optimize care for patients with pulmonary embolism.

Revisit Knowledge Check Question

Pulmonary Embolism Response Teams aim to:

A. provide interdisciplinary care for severe pulmonary embolism
B. provide rapid clinical assessment and triage for patients with severe pulmonary embolism
C. improve quality of care, research, and education through the PERT Consortium
D. all of the above

The correct answer is all of the above.

The first Pulmonary Embolism Response Team was created by a multidisciplinary team of physicians and a major academic center in 2012. Their intent was to develop the necessary clinical, education, and research infrastructure for the advancement of pulmonary embolism care.

Since then, this multidisciplinary approach has allowed for the streamlined evaluation of patients, formulation of comprehensive treatment plans and the rapid mobilization of resources to provide the highest level of care to those patients with PE in need.

Since then, the PERT Consortium was developed to unite the efforts of PERT teams across the U.S. and internationally. The purpose of the PERT Consortium is to serve the general public by undertaking activities to advance the status of pulmonary embolism care and promote research in the treatment of pulmonary embolism.

Revisit Learning Objectives

You should now be able to:

  1. List the specialties that may be involved in the care of a patient with acute pulmonary embolism
  2. Contrast PERT protocols for the treatment of high, low, and intermediate-risk pulmonary embolism
  3. Describe the benefits of a PERT approach for the patients with acute pulmonary embolism, and
  4. Describe challenges associated with instituting PERT approach to the patients with acute pulmonary
    embolism.
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