The Vancouver General Hospital Pulmonary Embolism Response Team (PERT): Preliminary Experience
CCCF ePoster library. Romano K. Nov 2, 2016; 150976
Dr. Kali Romano
Dr. Kali  Romano
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#95

Topic: Quality Assurance & Improvement

The Vancouver General Hospital Pulmonary Embolism Response Team (PERT): Preliminary Experience


Romano, Kali1; Finlayson, Gordon2; Ronco, Juan J.3; Legiehn, Gerald4, Griesdale Don E.2

1Department of Anesthesiology, University of British Columbia, Vancouver, British Columbia, Canada. 
2 Division of Critical Care Medicine Vancouver General Hospital, Department of Anesthesiology, University of British Columbia, Vancouver, British Columbia, Canada. 
Division of Critical Care Medicine Vancouver General Hospital, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
Division of Interventional Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada

 



Abstract:

Introduction:
Pulmonary embolism (PE) is a disease with increasing prevalence and significant attributable mortality. Therapeutic options for treating PE depend not only on clinical presentation, but also clinician preference, and institutional availability.  High risk PE patients intersect several medical & surgical specialties and demand urgent and coordinated management.  Motivated to improve patient care and inspired by the Massachusetts General Hospital Pulmonary Embolism Response Team (PERT)(1) we established a rapid response system to provide urgent assessment and multidisciplinary management for patients with high-risk pulmonary emboli. The first of its kind in Canada, the Vancouver General Hospital PERTeam aims to improve the quality of care for high risk PE patients.
 
Objective:  
To review the structure of the VGH PERTeam, as well as preliminary experience from the first six months.
 
Methods:
Structure: The VGH PERTeam is a multidisciplinary team of specialist physicians, nurses and respiratory therapists focused on providing specialized care of patients with confirmed high-risk PE. Similar in concept to the MGH PERT(1) this is achieved through a rapid notification system, as well as dedicated teleconference line to facilitate a multidisciplinary case discussion. At our institution, in the setting of radiologically confirmed high risk PE (RV strain, saddle embolism, clot in transit) the radiologist dials 8800 activating the PERTeam and notifying the most responsible physician (MRP).The PERTeam, using the pre-existing structure of the critical care outreach team (CCOT), coordinates a standardized assessment after which the CCOT Intensivist hosts a multidisciplinary teleconference involving the MRP, Intensive Care Unit (ICU), Interventional Radiologist and/or Cardiovascular Surgeon. If an interventional or surgical procedure is chosen, a Cardiac Anesthesiologist is notified to provide ongoing care for the patient during their procedure. Patients are subsequently managed in the high acuity unit (HAU) or ICU, with consultation to hematology and/or respirology for long-term care.   
 
Research: The VGH PERTeam also contributes to quality improvement through the collection of data from PE activations. Data is collected retrospectively, and entered into a Research Electronic Data Capture (REDCap) Database.
 
Results:
There were 24 PERT activations within the first 6 months. The majority of activations were patients admitted to the ER (14, 58.3%), with 7 (29.2%) from medical wards and 3 (12.5%) from surgical wards. 16 (69.6%) showed signs of RV dysfunction on CT. 1 patient presented in cardiac arrest. The majority of patients (23, 95.8%) were treated with therapeutic anticoagulation, 1 patient received systemic thrombolysis and suction thrombectomy, and 2 patients received catheter directed thrombolysis (2, 8.3%). There were major bleeding complications in 3 (12.5%) patients, with 1 patient suffering fatal intracranial hemorrhage on day 1 post catheter directed thrombolysis. Overall, there were 2 mortalities. 
 
Conclusion:
Clinical management of patients with high-risk PE requires a multidisciplinary approach. The VGH PERTeam facilitates urgent clinical assessment and coordination of a multidisciplinary team to manage patients with confirmed PE. Ongoing clinical implementation and data collection will aim to optimize the care of patients with high-risk PE at our institution.
 
 


References:
  1. Sista AK, Goldhaber SZ, Vedantham S, Kline JA, Kuo WT, Kahn SR, Kabrhel C, McLaughlin VV, White SB, Kim NH, Gray M, Simon MA, Benenati JF, Misra S, Sterling KM, Kee ST, Konstantinides SV, Jaff MR, Kearon C. Research Priorities in Submassive Pulmonary Embolism: Proceedings from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol. 2016 June; 27(6): 787-794.
  2. Center for Disease Control and Prevention [Internet]. Atlanta, GA: Center for Disease Control. 2015 [Cited 2016 Sept 4] Available from: http://www.cdc.gov/ncbddd/dvt/data.html
  3. Pollack CV, Schreiber D, Goldhaber SZ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol. 2011;57(6):700-706. 
  4. Provias T, Dudzinski DM, Jaff MR, Rosenfield K, Channick R, Baker J, Weinberg I, Donaldson C, Narayan R, Rassi AN, Kabrhel C. The Massachusetts General Hospital Pulmonary Embolism Response Team (MGH PERT): Creation of a Multidisciplinary Program to Improve Care of Patients With Massive and Submassive Pulmonary Embolism. Hospital Practice 2014. (42)1:31-37.


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