Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF September 8, 2017 | Archived Issues

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New Team Expedites Care of Pulmonary Embolism

The Cedars-Sinai Pulmonary Embolism Response Team (PERT) is a new multidisciplinary team that provides rapid triage and access to state-of-the-art care for intermediate and high-risk pulmonary embolism (PE), the third-leading cause of death after coronary artery disease and stroke.

The PERT team, which launched in May, includes specialists from pulmonary, critical care, cardiology, interventional cardiology and cardiothoracic surgery.

"Most people who are diagnosed with PE aren't diagnosed until death," said Victor Tapson, MD, pulmonary critical care and president of The National PERT Consortium. "PE can progress rapidly, and the death rate is high without treatment. Therapeutic options are evolving quickly, and our team aims to simplify identification and treatment of these cases."

Providers can call a dedicated phone line (3CLOT) for 24-hour access to the team, which activates all comprehensive care options for PE, including expert risk stratification, triage and therapeutic planning based on the clinical presentation and test results.

The pulmonary critical care fellow or attending will field the call, gather information and offer advice. In certain scenarios — such as high-risk (massive) PE (patients with hemodynamic instability) or a clot in transit — cardiology and cardiac surgery will be contacted.

The team will also help guide the decision to use systemic thrombolytics. If catheter-directed therapy is a consideration, interventional cardiology or interventional radiology will be contacted.

Intermediate risk PE can be quite heterogeneous, and the team will offer expert recommendations. All decisions — including anticoagulation alone, IVC filter placement and endovascular treatment — must be made quickly, and communication lines between team members and with the primary service must be open.

"PE is a disease that spans many different specialties — cardiology, interventional cardiology, pulmonary critical care, cardiothoracic surgery, interventional radiology and hematology in certain scenarios — so usually the provider has to make many calls. With 3CLOT, the provider makes one phone call," said Oren Friedman, MD, pulmonary critical care and cardiac surgery critical care. "There is now an abundance of different capabilities or treatment modalities that must be tailored specifically to a patient. The complexities of PE are understood, but patient-specific treatment is key."

The PERT expedites care and eliminates the need for numerous time-consuming communications, which can cause treatment delays. The team now offers coordination of multiple endovascular procedures, cardiac surgery and extracorporeal membrane oxygenation (ECMO).

The PERT team carefully assesses the patient's clinical status and study results, and provides rapid clinical evaluation and triage of high-risk PE patients.

In addition to inpatient treatment, the team monitors patients after they leave the hospital at the PE outpatient clinic. Follow-up management for pulmonary embolism is crucial, as there are many nuances and options for long-term anticoagulation. The rise of direct oral anticoagulants has introduced many more options for long-term care, including low-dose extended anticoagulation.

PERT members include:

  • Victor Tapson, MD, pulmonary critical care
  • Aaron Weinberg, MD, pulmonary critical care
  • Oren Friedman, MD, pulmonary critical care, cardiac surgery critical care
  • Suhail Dohad, MD, interventional cardiology
  • Danny Ramzy, MD, cardiothoracic surgery
  • Hooman Madyoon, MD, interventional cardiology
  • David Hildebrandt, BSN, Heart Institute team manager
  • Interventional radiology team

The Cedars-Sinai PERT is a founding member of The National PERT Consortium initiated by Massachusetts General Hospital. The consortium hosts annual meetings to discuss developments in PE care and provides a forum for members to share information on care and research.

Cedars-Sinai will contribute to a national database and will be able to publish from this database. The PERT Consortium newsletter has featured the Cedars-Sinai PERT's approach and its access to multiple modalities of advanced PE care — including the robust cardiac surgery and ECMO programs, which have opened the door to aggressive PE treatment not routinely available at many large centers.

A number of clinical trials and research projects are underway. For more information on the PERT, email victor.tapson@cshs.org.