Multidisciplinary PE response teams streamline care


By Mardi Chapman

2 Apr 2024

Multidisciplinary pulmonary embolism response teams (PERTs) including haematologists have the potential to fast-track optimal care for high and intermediate risk PE patients, Australian experience shows.

Respiratory physician Dr Jimmy Chien, clinical lead for the PERT at Westmead Hospital, told the Thoracic Society of Australia and New Zealand (TSANZ) 2024 ASM that management of PE generally remained quite variable despite being common and life threatening.

He said a 2022 scoping review and meta-analysis of PERTs [link here] had identified some of their likely advantages, including:

  • Reduced variability in therapeutic approach
  • Improved risk stratification
  • Improved selection of advanced therapies
  • Help navigating the gaps in guidelines and evidence
  • Education of peers and trainees
  • Leveraging the unique perspectives of other specialists
  • Fostering pathways for patient follow-up.

Dr Chien said the Westmead PERT took years to set up – from formation of a working group in 2016 through drafting algorithms, establishing consensus, PERT management of a trial cohort, simulation sessions, formal clinical governance and executive support, and review of early outcomes.

A description of the first 36 months of the Westmead PERT which managed 75 consecutive patients between August 2018 and July 2021 has just been published in the Internal Medicine Journal [link here].

The PERT consists of specialists from respiratory medicine, emergency, haematology, interventional radiology, and intensive care, with cardiothoracic and vascular surgeons participating as required.

It is activated by the on-call respiratory physician for any patient with acute PE thought to require urgent multidisciplinary input. Patients were mostly classified as intermediate-high risk (59%) and high-risk (24%) according to ESC guidelines.

About 22% had a history of VTE, 31% had hypertension, 31% had a solid malignancy and 26% had a period of recent immobilisation. As well, over 85% of patients had a sPESI score≥1, conferring a high mortality risk.

The study said all patients managed by the PERT received therapeutic anticoagulation prior to or shortly after PERT activation.

“…rapid PERT activation resulted in the majority of these patients receiving systemic thrombolysis; however, early PERT involvement permitted multispecialty input regarding other available therapeutic options for patients at higher risk of bleeding complications from systemic thrombolysis,” the study authors said.

About a third of high risk patients received either ultrasound-assisted catheter-directed thrombolysis (22%) or suction thrombectomy (11%) while 64% of intermediate-high risk patients and 50% of intermediate-low risk patients received ultrasound catheter-directed thrombolysis (US-CDT). As well, 7% of intermediate-high risk patients received suction thrombectomy and 2% surgical thrombectomy.

Minor bleeding following interventional radiology procedures was the most common complication. All-cause mortality was 6.8% and all deaths occurred within 7 days of admission.

Dr Chien said his experience at Westmead was that the PERT enabled rapid risk stratification of patients, a reduction in variation of clinical management, good coordination of all teams and services, and upskilling of team members.

“And it’s priceless education and training. We’ve had a lot of our registrars and fellows in this process who have found it very helpful and it’s also been very beneficial for research and data collection.”

He said the evidence for PERT was starting to build.

It includes a German experience with PERT published in Clinical Research in Cardiology [link here] which found implementation was associated with a lower risk of all-cause mortality in PE patients after the initiation of PERT compared to before PERT.

“And the salient point that I want to highlight is they said the role of PERT becomes even more important in relation to technical improvements and updated guidelines regarding catheter-directed strategies. These new technologies offer additional therapeutic options but they bring their own risks and benefits and these should be discussed in a PERT.”

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