The Implementation of a Pulmonary Embolism Response Team in the Management of Pulmonary Embolism
ELEFTHERIOS S XENOS, George Davis, Amanda Green, Qiang He, Susan Smyth
University of Kentucky Medical Center, Lexington, KY
INTRODUCTION: Massive and submassive pulmonary embolism (PE) can be life threatening. Management options include anticoagulation,systemic fibrinolysis,or interventional treatment with catheter directed or open surgical thrombus removal with or without extracorporeal membrane oxygenation .Currently most patients with PE, even if they are hemodynamically unstable, are treated with anticoagulation alone . With increasing patient complexity and several therapeutic options the optimal approach for patients with intermediate to high risk PE is not clearly established. The implementation of a clinical pathway executed by a multidisciplinary, rapid response team can optimize risk stratification and expedite management . To this end the Pulmonary Embolism Response Team(PERT)was created at our institution with specialists from vascular surgery, critical care, interventional radiology, emergency medicine, cardiac surgery and cardiology. The team used current evidence, knowledge and recommendations as well as institutional experience to reach consensus and to create a risk stratification and treatment algorithm for management of patients with massive and submassive PE . The team is organized as a rapid response team and is activated using a 24hr telephone number to evaluate and treat these patients using the algorithm. We review our initial experience with this approach.
METHODS: The records of patients that were are treated by the PERT in 2016(inception late 2015)and2017were reviewed(intervention group). The diagnoses codes of these patients were retrieved from the Vizient database and a retrospective control cohort group was created using these specific diagnoses and a matching set of demographics(age,gender,race),Medicare Severity Diagnosis Related Group(MSDRG), admission severity of illness(SOI)and admission risk of mortality(ROM). Statistical analysis was performed using the Fisher's exact test , the Pearson chi-square statistic,Student's t-test and Cochran-Cox approximation. P<0.05 was considered significant.
RESULTS: 77 patients were treated by activation of the PERT pathway. 992 patients were included in the control group, these patients were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of ROM and SOI and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower ICU stay and overall length of stay (LOS). No difference was seen in direct cost between the two groups. The results are summarized in the table.There was higher utilization of interventional treatment in the PERT group 57% vs. 40% for control.
CONCLUSIONS: In our institution patients with massive or submassive PE are managed by a dedicated team that implements a clinical algorithm developed by the team . This results in expedited treatment and reduced variation of care. ICU stay and overall LOS are reduced by this approach and the direct cost is not increased despite the use of advanced modalities of treatment. We feel that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved .
| Length of stay | ICU Days | Direct Cost | Mortality rate | |||||
| control | PERT | control | PERT | control | PERT | control | PERT | |
| Mean | 9.22 days | 6.31 days | 6.86 days | 4.4 days | $12,219.70 | $16,843.20 | 13.38% | 15.07% |
| Standard deviation | 16.09 days | 7.44 days | 9.35 | 5.05 | $20,957.60 | $25,242.50 | ||
| Cochran P value | 0.004 | 0.006 | 0.12 | 0.72 | ||||
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