What is PERT and How Can it Help Triage the PE Patient?

In this video, Kenneth Rosenfield, MD, discusses the advent of the Pulmonary Embolism Response Team (PERT) and reviews a case study where PERT was implemented. PERT was created because of the inability to respond rapidly to patients with PE. He saw that PE strategies were all over the map and there were no clear assessment or treatment guidelines. PERT leverages the input of a multidisciplinary team of experts and coordinates the care amongst all the services involved with PE; develops protocols for the full range therapies available; and collects data on efficacy. In response to interest in the program outside of Mass General, the PERT Consortium was launched.

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Transcript

Because we've got to catch up a little bit. We have important satellite sessions during the lunch break. You know we're suggesting that everyone use the hashtag #PERT2016 if you're a tweeter.

So, let's talk about the real world again. Because that's actually what I was referring to when I addressed our incredible panel. That is an amazing panel, next year's meeting we're going to expand and probably allow for an hour discussion because I think we could go on for at least an hour.

So what about this 37-year-old male, recovering from knee surgery. After defecating, feels dizzy and presents with a large pulmonary embolism. PO2 of 80, resuscitated with oxygen and fluid, and transferred to our place where he has clot in transit at MGH. You can see his coronal view of large pulmonary embolism, and the question is in that kind of case, what do you do? How do you make a decision? Who makes a decision, and on what basis do they do that?

Or, in this 54-year-old guy who presents with sudden onset of shortness of breath and left pleuritic chest pain. Has a heart rate of 112, that's probably the best marker. Respiratory rate, 22 and his SATs 89%. He has a large pulmonary embolism, large volume pulmonary embolism, not nearly as unstable as the other patient. Troponin at 1.5, BNP at 3400 and his echo shows dilated RV and a high RV to LV ratio. So what to do? And who makes these decisions on a day-to-day basis in your emergency rooms?

You have all these alternatives. Anti-coagulation alone on the left and which agent do you use? And on the right side you have thrombolysis or mechanical clot removal or surgery. And we have Thoralf Sundt's talk this afternoon about the surgical applications. How do we decide which therapy to apply to any given patient?

Well, I would submit that less than 5% of patients with PE receive advanced therapies and maybe with good reason in most cases. But, I think there are some who would benefit, and I sort of describe that patient of mine who clearly benefited from it. And, by the way, she made that decision. She participated in a GoToMeeting call where she actually weighed in and said, "I want this. I want to take that chance."

So, why don't people make the decisions to sort of move forward? There's a fear of potential complications. Bleeding, primarily and frankly, there are also systems issues. The inability to respond rapidly to a situation like that in the ED and there's a paralysis in decision-making that occurs as a result. So, what do we do?

In the setting of this, about three and a half years ago at our place, we got together and said, well, we were a little after you Nills, you started in 2010, we started in 2012, we said, "The strategies are all over the map here at Mass General." If you're a patient presenting in the ED or orthopedics floor, or the neurosurgical floor or medicine, there's no standard algorithm. Everybody gets what the responding clinician decides based on their interpretation of the guidelines and their interpretation over the patient's desires. There's no single team or clearinghouse and no centralized location for that care. And we weren't evaluating the results in a systemic way, so we decided that we need to change this.

And we created this thing called the "PERT." The Pulmonary Embolism Response Team. I'll give Rich Chanick the nod for having come up with the name. And our mission was to advance the diagnosis, treatment and outcomes of our patients with PE and to improve the patient outcomes using a multidisciplinary, collaborative, team-based approach in an urgent consultative way, which is different than most places do. It's a little bit like cancer, well, cancer centers you get together. The oncologist and the surgeon and the radiation oncologist they talk, but it's not urgent consultation. So, we had to figure out how to make that happen in an urgent way so we can make decisions in a rapid way about patients. It's also different than Acute MI, for example, where everybody kind of knows what the guidelines say, and there's only one specialty making the decision.

Well, here we're talking about multiple specialties. So, how do we make that happen? How do we change this chaos which used to exist when a patient presented with pulmonary embolism at Mass General to something like this which is pretty cohesive and pretty unified. So, what we did was we created a multidisciplinary, collaborative, team approach. We sat around a table, about seven or eight disciplines and said, "How are we going to do this together and all have input in a rapid way into what happens with the patients?"

Well, this is about three, four years ago with the core of the PERT team, or a few of them. There was probably double at that time, now it's about four times that size. And the objectives of the PERT team were to respond expeditiously to treat these patients with massive and submassive large pulmonary emboli, not the small sub-segmental things. To provide those patients the best therapeutic options. For that patient to leverage the input of a multidisciplinary team of experts and coordinate the care amongst all the services involved with PE. And to develop protocols for the full range of therapies available. To collect data on how the patients were presenting and how we were treating them and were we effective. We saw this as a very big unmet clinical need and we needed to add to the evidence base to allow the guidelines to actually reflect the next level.

We set up posters all around the hospital. "Call this one number if you have a patient with a large pulmonary embolism: 4PERT."

We developed the flow map, and what you can see here is if it's a low risk PE up there in the green, then it goes directly to coagulation, we don't really spend a lot of time. But if it's a massive or sub-massive, especially if it's a high-risk sub-massive, using the European guidelines approach, we convene an electronic meeting of all of the folks involved, and here's an example of a GoToMeeting that is coordinated by my fellows or the critical care pulmonary fellows.

We leverage that low cost available modality of GoToMeeting and send around emails and pages saying go to a meeting in 30 minutes, in 20 minutes or 15 minutes about a patient that we've just seen with PE. And afterwards we discuss it and we come up with a consensus decision about what the best treatment is for that patient based on guidelines and our own knowledge base that we developed.

We describe this in a couple of articles, in Chest and Hospital Practice and we started getting calls from all over the world, all over the country at least, asking, "What are you guys doing? That's a really cool idea. We'd like to do the same thing." So like a year ago, we launched a consortium. At that time we expected about 15 centers and about 30 providers because that's what we thought had been calling us. We ended up with 40 institutions and 85 people in a room like this who were industriously, feverishly working on how to create this consortium that was all like-minded in the way this PERT approach would work.

This year, yesterday, we had our second annual meeting, and we had over 130-140 people in this room representing about 80 institutions. There are another couple hundred people at home who couldn't make it.

So, this is our definition, this is what my talk is. How do you define it? A pulmonary embolism response team is an institutionally-based multidisciplinary team that has the ability to rapidly assess and provide treatment for patients with acute PE. Has a formal mechanism to exercise a full range of the treatments available. Medical, surgical and endovascular. And you if you don't have the surgical treatment, for example, in house, at least you have the ability to access that quickly for your patients. And you can provide appropriate multidisciplinary follow-up with these patients and collect and evaluate and share data about the outcomes.

So, what about that 37-year-old guy who had had knee surgery. He had a clot in transit that we noticed on our CTA, and we were planning to extract that, based on the PERT call with a vortex extraction catheter. And the team was assembled in the cath lab, this was around midnight, and I can tell you that the patient suddenly precipitously decompensated. Wanted to urinate before he went upstairs. Went to the bathroom and crashed. Blood pressure went down to zero, he was on CPR and we rushed our team down from the cath lab. Because we had assembled them, because we had the PERT call, because we had actually done all the preparation, we were very quickly able to crash his onto ECMO while CPR was ongoing. We had him on there within five minutes. And it was used as a bridge to definitive therapy. Two days later he went to the operating room and has this clot extracted and I saw him literally two weeks afterwards, in the office walking around and doing fine. He's now three and a half years out and is doing great.

This is an example of how the PERT concept can actually have an effect. I can tell you in the 400, how many calls? 650 calls, Chris? 650 odd calls that we've had over the past three and a half years, I think and I think every one of our team members would agree that this concept has actually profoundly influenced the way that we manage pulmonary embolism at Mass General Hospital. And those of you, I don't know if this is true in Baron as well, Nills? But you can speak to this. I think it probably has affected the way that pulmonary embolism is managed there. It's a way to use those guidelines and apply them in individual situations and modify them.

It's also, potentially, a way to look at some of these new therapies that are coming down the road. Novel anticoagulants, ultrasound facilitated lysis, VORTEX, Inari, Penumbra, other ways to extract clot. And whether ECMO, which is now used increasingly in saving lives in patients with pulmonary embolism. Whether this will have an influence and how should we integrate these into our existing therapeutic modalities.

So, as an overall perspective. I think in the era of rising health care costs and limited resources, it's really time to get serious about evidence-driven therapy in pulmonary embolism. And that will require systematic collection of high-level, clean data that will enable us to develop a comprehensive and believable evidence base which requires collaboration and cooperation across disciplines caring for pulmonary embolism, and team-based care, I believe, will provide the optimal decision-making and therapeutic benefit for our patients.

And in the setting of the consortium, we hope to better understand pulmonary embolism. We have a lot to learn. There's a heightened awareness. I think it's an under-recognized and under-treated problem. The Pulmonary Embolism Response Team is a model type of program of interdisciplinary collaboration that enables us to streamline and optimize care. And this national PERT consortium, which is gaining enormous momentum and now International PERT consortium or international collaboration, I think will enhance the knowledge base that we can bring to the guideline writers so that we can get it right as we move forward. Even better, even more right.

So, thank you very much.

Refer a patient to the Fireman Vascular Center

Learn about the PERT Consortium