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Journal of Thrombosis and Thrombolysis

, Volume 47, Issue 1, pp 31–40 | Cite as

Changes in treatment and outcomes after creation of a pulmonary embolism response team (PERT), a 10-year analysis

  • Rachel RosovskyEmail author
  • Yuchiao Chang
  • Kenneth Rosenfield
  • Richard Channick
  • Michael R. Jaff
  • Ido Weinberg
  • Thoralf Sundt
  • Alison Witkin
  • Josanna Rodriguez-Lopez
  • Blair A. Parry
  • Savannah Harshbarger
  • Praveen Hariharan
  • Christopher Kabrhel
Article

Abstract

Multidisciplinary pulmonary embolism response teams (PERTs) are being implemented to improve care of patients with life-threatening PE. We sought to determine how the creation of PERT affects treatment and outcomes of patients with serious PE. A pre- and post-intervention study was performed using an interrupted time series design, to compare patients with PE before (2006–2012) and after (2012–2016) implementation of PERT at a university hospital. T-tests, Chi square tests and logistic regression were used to compare outcomes, and multivariable regression were used to adjust for differences in PE severity. Two-sided p-value < 0.05 was considered significant. For the interrupted time-series analysis, data was divided into mutually exclusive 6-month time periods (11 pre- and 7 post-PERT). To examine changes in treatment and outcomes associated with PERT, slopes and change points were compared pre- and post-PERT. Two-hundred and twelve pre-PERT and 228 post-PERT patients were analyzed. Patient demographics were generally similar, though pre-PERT, PE were more likely to be low-risk (37% vs. 19%) while post-PERT, PE were more likely to be submassive (32% vs. 49%). More patients underwent catheter directed therapy (1% vs. 14%, p = < 0.0001) or any advanced therapy (19 [9%] vs. 44 [19%], p = 0.002) post PERT. Interrupted time series analysis demonstrated that this increase was sudden and coincident with implementation of PERT, and most noticeable among patients with submassive PE. There were no differences in major bleeding or mortality pre- and post-PERT. While the use of advanced therapies, particularly catheter-directed therapies, increased after creation of PERT, especially among patients with submassive PE, there was no apparent increase in bleeding.

Keywords

Pulmonary embolism Pulmonary embolism response team PERT Treatment Thrombolysis 

Notes

Acknowledgements

The authors thank Janet McClintic, MHA, for the administrative support she provided for this work. They thank the employed research staff of the Center for Vascular Emergencies for their assistance with data collection: Erin Deadmon and Nicholas Giordano. They also greatly appreciate the efforts of the clinical fellows who contributed to the care of pulmonary embolism response team patients and the collection of data used in this manuscript: Michael Nguyen Young, Rasha Fahad Al-Bawardy, Mazen Albaghdadi, and Jorge Borges. None were compensated for their contributions.

Author contributions

RR had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Rosovsky, Chang, Kabrhel. Acquisition, analysis, or interpretation of data: Rosovsky, Chang, Rosenfield, Channick, Jaff, Weinberg, Sundt, Witkin, Rodriguez-Lopez, Parry, Harshbarger, Hariharan, Kabrhel. Drafting of the manuscript: Rosovsky, Chang and Kabrhel. Critical revision of the manuscript for important intellectual content: Rosovsky, Chang, Rosenfield, Channick, Jaff, Weinberg, Sundt, Witkin, Rodriguez-Lopez, Parry, Harshbarger, Hariharan, Kabrhel. Final approval of the manuscript: Rosovsky, Chang, Rosenfield, Channick, Jaff, Weinberg, Sundt, Witkin, Rodriguez-Lopez, Parry, Harshbarger, Hariharan, Kabrhel. Statistical analysis: Chang.

Compliance with ethical standards

Conflict of interest

Chang, Channick, Weinberg, Witkin, Parry, Harshbarger, Hariharan declared that they have no conflict of interest. Rosovsky discloses the following relationships: grant recipient from Bristol Meyer Squibb and Janssen Pharmaceuticals; consultant to Bayer. Rosenfield discloses the following relationships: consultant to: Cardinal Health and SurModics; grants/contracts with Abbott Vascular, Atrium, Lutonix/BARD, and The Medicines Company; equity with Access Closure, Inc., and AngioDynamics/Vortex; personal compensation from Cook, HCRI, and The Medicines Company; board member with VIVA Physicians. Jaff discloses the following relationships: non compensated advisor to Abbott Vascular, Boston Scientific, Cordis, and Medtronic; equity with Vascular Therapies, PQ Bypass, Valiant Medical, and Primacea; board Member with VIVA Physicians (a 501 c 3 not-for-profit education and research). Sundt discloses the following relationship: consultant to Thrasos Therapeutics. Rodriguez-Lopez discloses the following relationships: Grant Support-Actelion pharmaceuticals. Consulting- Gilead pharmaceuticals. Kabrhel discloses the following relationships: consultant to Diagnostica Stago, Janssen Pharmaceuticals, Siemens, Pfizer, and Portola Pharmaceuticals; grant recipient from Diagnostica Stago, Siemens Healthcare, Janssen Pharmaceuticals, and Boehringer-Ingelheim.

Informed consent

Informed consent was not necessary or obtained as this was part of our program’s quality assurance/quality initiative and was a non interventional study.

Research involving human participants

All studies were approved by the Human Research Committee of Partners HealthCare Inc. (2012-P-002257, 2008-P-002001).

References

  1. 1.
    Office of the Surgeon General (US), National Heart, Lung, and Blood Institute (US) (2008) The surgeon general’s call to action to prevent deep vein thrombosis and pulmonary embolism. Office of the Surgeon General (US), RockvilleGoogle Scholar
  2. 2.
    Pollack CV, Schreiber D, Goldhaber SZ et al (2011) 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 57(6):700–706CrossRefGoogle Scholar
  3. 3.
    Stein PD, Matta F (2011) Epidemiology and incidence: the scope of the problem and risk factors for development of venous thromboembolism. Crit Care Clin 27(4):907–932CrossRefGoogle Scholar
  4. 4.
    Centers for Disease C, Prevention (2012) Venous thromboembolism in adult hospitalizations—United States, 2007–2009. MMWR Morb Mortal Wkly Rep 61(22):401–404Google Scholar
  5. 5.
    Puurunen MK, Gona PN, Larson MG, Murabito JM, Magnani JW, O’Donnell CJ (2016) Epidemiology of venous thromboembolism in the Framingham Heart Study. Thromb Res 145:27–33CrossRefGoogle Scholar
  6. 6.
    Goldhaber SZ, Visani L, De Rosa M (1999) Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 353(9162):1386–1389CrossRefGoogle Scholar
  7. 7.
    Kline JA, Nordenholz KE, Courtney DM et al (2014) Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost 12(4):459–468CrossRefGoogle Scholar
  8. 8.
    Kucher N, Boekstegers P, Muller OJ et al (2014) Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 129(4):479–486CrossRefGoogle Scholar
  9. 9.
    Kuo WT, Banerjee A, Kim PS et al (2015) Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): initial results from a prospective multicenter registry. Chest 148(3):667–673CrossRefGoogle Scholar
  10. 10.
    Leacche M, Unic D, Goldhaber SZ et al (2005) Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 129(5):1018–1023CrossRefGoogle Scholar
  11. 11.
    Meyer G, Vicaut E, Danays T et al (2014) Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 370(15):1402–1411CrossRefGoogle Scholar
  12. 12.
    Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M, Investigators M (2013) Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol 111(2):273–277CrossRefGoogle Scholar
  13. 13.
    Piazza G, Hohlfelder B, Jaff MR et al (2015) A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II study. JACC Cardiovasc Interv 8(10):1382–1392CrossRefGoogle Scholar
  14. 14.
    Kabrhel C, Jaff MR, Channick RN, Baker JN, Rosenfield K (2013) A multidisciplinary pulmonary embolism response team. Chest 144(5):1738–1739CrossRefGoogle Scholar
  15. 15.
    Kabrhel C, Rosovsky R, Channick R et al (2016) A multidisciplinary pulmonary embolism response team (PERT)-initial 30-month experience with a novel approach to delivery of care to patients with sub-massive and massive PE. Chest 150(2):384–393CrossRefGoogle Scholar
  16. 16.
    Provias T, Dudzinski DM, Jaff MR et al (2014) 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. Hosp Pract 42(1):31–37CrossRefGoogle Scholar
  17. 17.
    Monteleone PP, Rosenfield K, Rosovsky RP (2016) Multidisciplinary pulmonary embolism response teams and systems. Cardiovasc Diagn Ther 6(6):662–667CrossRefGoogle Scholar
  18. 18.
    Bloomer TL, Thomassee EJ, Fong PP (2015) Acute pulmonary embolism network and multidisciplinary response team approach to treatment. Crit Pathw Cardiol 14(3):90–96CrossRefGoogle Scholar
  19. 19.
    Dudzinski DM, Piazza G (2016) Multidisciplinary pulmonary embolism response teams. Circulation 133(1):98–103CrossRefGoogle Scholar
  20. 20.
    Witkin AS, Harshbarger S, Kabrhel C (2016) Pulmonary embolism response teams. Semin Thromb Hemost 42(8):857–864CrossRefGoogle Scholar
  21. 21.
    Barnes G, Giri J, Courtney DM et al (1995) Nuts and bolts of running a pulmonary embolism response team: results from an organizational survey of the National PERT Consortium members. Hosp Pract 2017:1–5Google Scholar
  22. 22.
    Barnes GD, Kabrhel C, Courtney DM et al (2016) Diversity in the pulmonary embolism response team model: an organizational survey of the national PERT consortium members. Chest 150(6):1414–1417CrossRefGoogle Scholar
  23. 23.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381CrossRefGoogle Scholar
  24. 24.
    Kabrhel C, Okechukwu I, Hariharan P et al (2014) Factors associated with clinical deterioration shortly after PE. Thorax 69(9):835–842CrossRefGoogle Scholar
  25. 25.
    Hariharan P, Takayesu JK, Kabrhel C (2011) Association between the pulmonary embolism severity index (PESI) and short-term clinical deterioration. Thromb Haemost 105(4):706–711CrossRefGoogle Scholar
  26. 26.
    Jaff MR, McMurtry MS, Archer SL et al (2011) 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 123(16):1788–1830CrossRefGoogle Scholar
  27. 27.
    Kearon C, Akl EA, Ornelas J et al (2016) Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 149(2):315–352CrossRefGoogle Scholar
  28. 28.
    Konstantinides SV, Torbicki A, Agnelli G et al (2014) 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 35(43):3033–3069CrossRefGoogle Scholar
  29. 29.
    Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV (2009) Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol 20(11):1431–1440CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Rachel Rosovsky
    • 1
    Email author
  • Yuchiao Chang
    • 2
  • Kenneth Rosenfield
    • 3
  • Richard Channick
    • 4
  • Michael R. Jaff
    • 5
  • Ido Weinberg
    • 3
  • Thoralf Sundt
    • 6
  • Alison Witkin
    • 4
  • Josanna Rodriguez-Lopez
    • 4
  • Blair A. Parry
    • 7
  • Savannah Harshbarger
    • 7
  • Praveen Hariharan
    • 7
  • Christopher Kabrhel
    • 7
  1. 1.Division of Hematology and Oncology, Department of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  2. 2.Division of General Internal Medicine, Department of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  3. 3.Division of Cardiology, Department of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  4. 4.Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  5. 5.Department of MedicineNewton Wellesley HospitalNewtonUSA
  6. 6.Division of Cardiac Surgery, Department of Surgery, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  7. 7.Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA

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