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Correspondence |

A Multidisciplinary Pulmonary Embolism Response TeamPulmonary Embolism Response Team FREE TO VIEW

Christopher Kabrhel, MD, MPH; Michael R. Jaff, DO; Richard N. Channick, MD, FCCP; Joshua N. Baker, MD; Kenneth Rosenfield, MD
Author and Funding Information

From the Department of Emergency Medicine (Dr Kabrhel); the Division of Cardiology and Vascular Medicine (Drs Jaff and Rosenfield); the Division of Pulmonary/Critical Care (Dr Channick), Department of Medicine; and the Division of Cardiac Surgery (Dr Baker), Department of Surgery, Massachusetts General Hospital, Harvard Medical School.

Correspondence to: Christopher Kabrhel, MD, MPH, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Pl, Ste 3B, Boston, MA 02114; e-mail: ckabrhel@partners.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(5):1738-1739. doi:10.1378/chest.13-1562
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Published online
To the Editor:

In this report, we describe the successful introduction of a novel Pulmonary Embolism Response Team (PERT) to streamline the care of patients with severe pulmonary embolism (PE). The treatment of patients with massive and submassive PE remains controversial.1 Different specialists bring different experience, technical expertise, and therapeutic recommendations.1,2 To provide optimal care for complex patients with PE, a team approach is required. We formed the PERT with an infrastructure that would provide rapid, multidisciplinary consultation; mobilize resources; and facilitate research.

The PERT is composed of specialists in cardiology, emergency medicine, vascular medicine, cardiac surgery, and pulmonary/critical care with an interest in PE. We created an activation system consistent with published guidelines for rapid response teams.3,4 An on-call PERT fellow responds to an activation and immediately convenes an online meeting of PERT members using commercially available software. This system enables team members to discuss the case while viewing data and radiologic images from any computer or mobile device via a password-protected login.

In the first 12 weeks, there were 30 unique PERT activations. Most (17, 57%) originated in the ED, seven (23%) in ICUs, and six (20%) in inpatient hospital units. Twenty-five activations (83%) were for confirmed PE and five (17%) for unstable patients with suspected PE. Median elapsed time from the initial activation to the multidisciplinary online meeting was 54 min (25%-75%: 52-72 min). Data collection was approved by the Human Research Committee of Partners Healthcare (2012P002257).

The mean age of patients was 57 ± 17 years, and 19 (63%) were men (Table 1). Seven of 25 confirmed PEs (28%) were saddle and eight (32%) involved a main pulmonary artery. Twenty patients (80%) had right-sided heart strain. After consultation, the PERT considered 18 PEs (72%) submassive and two (8%) massive (Fig 1). Two patients (8%) were treated with thrombolysis (via catheter), 12 (40%) had a contraindication to thrombolysis, and five (20%) had a vena cava filter placed. Three patients (12%) with confirmed PE died.

Table Graphic Jump Location
Table 1 —Characteristics of Enrolled Patients

NT-proBNP = N-terminal pro-brain natriuretic peptide; PE = pulmonary embolism.

a 

Includes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis.

b 

Within 4 wk of PE.

c 

Based on echocardiogram or CT pulmonary angiogram.

d 

Based on extremity ultrasound or CT venography.

e 

Endotracheally intubated at time of Pulmonary Embolism Response Team activation.

Figure Jump LinkFigure 1. PE characterization and treatment. *One patient with submassive PE received both CDT and an IVC filter; **One patient with massive PE had an absolute contraindication to anticoagulation. CDT = catheter-directed thrombolysis; IVC = inferior vena cava; PE = pulmonary embolism; PERT = Pulmonary Embolism Response Team.Grahic Jump Location

To the authors’ knowledge, the PERT at Massachusetts General Hospital is the first such team in the country. Our initial experience suggests that an innovative, multidisciplinary PERT can streamline the care of patients with severe PE and that there is high demand for this approach.

References

Jaff MR, McMurtry MS, Archer SL, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16):1788-1830. [CrossRef] [PubMed]
 
Imberti D, Ageno W, Manfredini R, et al. Interventional treatment of venous thromboembolism: a review. Thromb Res. 2012;129(4):418-425. [CrossRef] [PubMed]
 
Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams [published correction appears inCrit Care Med. 2006;34(12):3070]. Crit Care Med. 2006;34(9):2463-2478. [CrossRef] [PubMed]
 
Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139-146. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. PE characterization and treatment. *One patient with submassive PE received both CDT and an IVC filter; **One patient with massive PE had an absolute contraindication to anticoagulation. CDT = catheter-directed thrombolysis; IVC = inferior vena cava; PE = pulmonary embolism; PERT = Pulmonary Embolism Response Team.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Characteristics of Enrolled Patients

NT-proBNP = N-terminal pro-brain natriuretic peptide; PE = pulmonary embolism.

a 

Includes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis.

b 

Within 4 wk of PE.

c 

Based on echocardiogram or CT pulmonary angiogram.

d 

Based on extremity ultrasound or CT venography.

e 

Endotracheally intubated at time of Pulmonary Embolism Response Team activation.

References

Jaff MR, McMurtry MS, Archer SL, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16):1788-1830. [CrossRef] [PubMed]
 
Imberti D, Ageno W, Manfredini R, et al. Interventional treatment of venous thromboembolism: a review. Thromb Res. 2012;129(4):418-425. [CrossRef] [PubMed]
 
Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams [published correction appears inCrit Care Med. 2006;34(12):3070]. Crit Care Med. 2006;34(9):2463-2478. [CrossRef] [PubMed]
 
Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139-146. [CrossRef] [PubMed]
 
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