Hello again from the Communications Committee!
We hope you’ve been enjoying our “Spotlight on a PERT” series! Each month we send a set of questions to a different PERT from around the country to get a sense of how they handle pulmonary embolism at their institution. This mini-interview is then shared with the whole Consortium to help new PERTs get started and experienced groups to see how others work “behind the scenes.”
Each month we’ll be interviewing a different team, so please let us know if you’d like to be next (or if you have other ideas for questions)! Many thanks to Cedars Sinai PERT for being our first West Coast interview!
As always, check us out on twitter (@PERTConsortium) for more updates or with insights into how you run your PERT.
Victor F. Tapson MD
Division of Pulmonary & Critical Care Medicine
Cedars-Sinai
Los Angeles, California
How long has your institution had a PERT?
Cedars has had a PERT for 2 years and a formal call scheduled with dedicated line (3-CLOT) for activation for approximately 6 months.
Who participates on the PERT team?
Key individuals from pulmonary, interventional cardiology, CT surgery, and interventional radiology participate. The founding personnel involved with organizing the team at Cedars have been: Vic Tapson, MD, Suhail Dohad, MD, Danny Ramzy, MD, PhD, Oren Friedman, MD, Aaron Weinberg, MD, David Hildebrandt, RN. Not all faculty from these divisions / departments participate, only key individuals who have a major interest in PE. We have a superb relationship with our ED, and the director Sam Torbati has worked closely with us as the program has evolved.
How is the team activated?
Clinician calls 3-CLOT and the page operator then calls pulmonary fellow (consult fellow during day and MICU fellow at night).
They get initial info and gather information. If the PE patient is high-risk or intermediate-high risk (by our definition, not ESC definition), or has any substantial concerns, the fellow immediately notifies primary pulmonary or cardiology attending who is on call. Otherwise, they may wait 30 to 60 minutes to gather information.
With certain scenarios, such as high-risk PE, clot-in-transit cases, etc, or when pulmonary embolectomy or ECMO is a consideration, cardiac surgery is immediately contacted.
How does the team communicate?
We do not have a formal call with all specialties involved for every PERT request. The primary pulmonologist or cardiologist on call does the initial screen. If a patient for example has BP of 60 systolic on three pressors and is deteriorating, systemic thrombolytic therapy may be ordered by the primary pulmonologist on call. The cardiac surgeon is often notified in these settings if ECMO is to be considered.
If the patient is more stable but may be a candidate for an interventional procedure, then interventional cardiology / radiology is contacted.
A unique feature of our program is that Cedars has a robust and active mechanical circulatory support program, and specifically rapid access to ECMO. Our cardiac surgeon Danny Ramzy is also an ECMO/ MCS surgeon and this allows us to be very aggressive with clot retrieval devices including Inari Flow Triever and Angiovac and even high risk CDT candidates, because we can use ECMO as a bridge to intervention or as backup if the patient decompensates.
We may do team calls or rapid team texting when necessary.
What improvements have you seen in patient care with the introduction of the PERT concept?
Our PERT consult patients are always offered the option of follow up in our PE clinic. We have approximately 200 patients currently followed. Patients are followed until discharge, either formally or, if issues are addressed, informally. Patients who are already followed by a clinician (e.g., pulmonologist, cardiologist, or hematologist) may or may not follow up in our PERT clinic.
Our program is improving / advancing with regard to awareness and number of calls, as well as in terms calls from outside hospitals for referrals. This aspect requires further thought and organization in terms of how to approach assessment and possible transfer, as well as the difficult area of offering advice on unseen patients. The speed with which interventions are arranged and performed appears to be increasing.
We have a nurse specialist (David Hildebrandt, RN) who was recruited to Cedars based on his experience with code teams and emergency interventional (e.g., STEMI) cardiac procedures, to help with or PERT.
We have a number of clinical trials in acute PE at Cedars. We enroll patients whenever possible. The evidence base for acute PE therapy is at present, inadequate.
How do you see your team evolving in the future?
Our future will involve joining the PERT consortium founded by MGH. This will enable our participation in registries and clinical trials and further advance the field. We will seek to recruit truly passionate multispecialty individuals to share call and meet with us to help advance the program.
What advice would you give to a new hospital looking to start a PERT?
Advice to others interested in starting a team would be to be sure to set the program up so that a PERT call will be reliably answered and responded to quickly, and consistently. The team has to work well together and interface seamlessly. There has to be a general understanding in the general approach to various scenarios. Complete agreement by team members is unrealistic, however. Meeting consistently, e.g. monthly, is crucial.