Considerations in Forming a PERT
With pulmonary embolism response teams gaining traction in the United States, there are pros and cons to implementing this type of team-based approach for your PE patients.
Pulmonary embolism (PE) is the fourth leading cause of cardiovascular death and a leading cause of cardiovascular morbidity worldwide.1 Importantly, not all PEs present in the same way. In fact, most PEs are either asymptomatic or represent low hemodynamic risk to patients. Nonetheless, an important minority of PEs will pose an immediate threat to patients’ lives.2 Accordingly, PEs are divided into low-, intermediate-, and high-risk categories.3 Although the backbone of PE treatment is prompt and adequate anticoagulation, other treatments are often considered for patients who present with intermediate- or high-risk PE. Examples of advanced therapies for PE are outlined in Table 1. The choice and implementation of these treatments are often a matter of clinical challenge and debate among experts in the field. Examples of dilemmas and open questions in PE treatment are outlined in Table 2.
RATIONALE FOR PULMONARY EMBOLISM RESPONSE TEAMS
Despite the high prevalence and complex nature of the disease, PE is not treated by a single discipline, but rather by an eclectic group of specialties including general internal medicine, hematology, pulmonology/critical care, cardiology/vascular medicine, cardiothoracic surgery, and more recently, vascular surgery and vascular interventional radiology. The term PERT (PE response team) has been coined to describe a team of specialties who come together to care for PE patients.4 Theoretical advantages and disadvantages of a team-based approach to PE are outlined in Table 3. As acute and chronic PE involves many subtleties, specialty and multidisciplinary care may theoretically result in better patient outcomes by bringing an array of complementary skill sets together for the benefit of patients.5
MAKEUP AND FORMATION OF A PERT
To date, several dozen PERTs have been active in the United States.6 Although they all have similar goals, their utilization and composition differ between centers. Creating the ideal PERT can be challenging because it requires that the clinical, procedural, and surgical skills be available to patients in a variety of inpatient and outpatient sites for the extent of the patient’s illness. It is our belief that, at a minimum, a PERT should be composed of representatives offering a particular set of services (Table 4). Importantly, the actual discipline of the team member is far less important than the quality of the skill provided. Despite the theoretical advantages to PERT formation, there are often obstacles when attempting to form and implement such a team-based approach to PE (Table 5).
As a general rule, it has been our experience that ensuring collaboration among all potential stakeholders in a particular health care system should offer higher chances of successful PERT implementation as compared to a narrower, specialty-based approach. Also, the triggers for PERT activation differ from center to center. A suggested protocol for PERT activation is presented in Figure 1.
CAVEATS TO IMPLEMENTING A PERT
It is worthwhile to mention that a competing approach would be to offer PE-related consultative services to a broader PE population (ie, to include low-risk PE patients). The advantages of this approach are accumulation of knowledge and experience, as well as ensuring that high-risk patients are not missed. However, we should caution that sometimes membership in a multidisciplinary team, such as a PERT, may result in a false sense of expertise about the disease process. The rapid evolution of PE care and the complex nature of PE patients can be cognitively demanding and require constant academic and clinical engagement. Several common misconceptions about PE are outlined in Table 6. Thus, important components of appropriate patient care are data collection for internal quality assurance purposes and continued specialty-level education. Periodic educational meetings, dedicated journal clubs, and morbidity and mortality meetings should be an integral part of any PERT initiative.
It is undeniable that PERTs have gained considerable traction and favor among many practitioners who perform pulmonary artery catheter-based procedures. However, further study is necessary to understand whether a team-based approach to PE results in improved patient outcomes or rather an overutilization of resources and increased cost, clinically relevant complications, and errors in care.
1. Dalen JE. Pulmonary embolism: what have we learned since Virchow? Natural history, pathophysiology, and diagnosis. Chest. 2002;122:1440-1456.
2. Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb Haemost. 2008;100:747-751.
3. Konstantinides SV. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35:3145-3146.
4. Kabrhel C, Rosovsky R, Channick R, et al. A multidisciplinary pulmonary embolism response team: initial 30-month experience with a novel approach to delivery of care to patients with submassive and massive pulmonary embolism. Chest. 2016;150:384-393.
5. Galmer AM, Selim SM, Giri J, et al. Building a critical limb ischemia program. Curr Treat Options Cardiovasc Med. 2016;18:50.
6. National Consortium of Pulmonary Embolism Response Teams website. http://www.pertconsortium.org. Accessed November 23, 2016.
Ido Weinberg, MD
Assistant Professor of Medicine
Harvard Medical School
Vascular Medicine Specialist
Massachusetts General Hospital
Mitchell D. Weinberg, MD
Director of Peripheral Vascular Intervention
North Shore University Hospital and Lenox Hill Hospital
Northwell Health System
New York, New York