Greetings from the Communications Committee!
We’re excited to send you all episode 2 of “Spotlight on a PERT,” a new initiative from our committee intended to give Consortium members an opportunity to observe “behind the scenes” how other PERTs are created and function. 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 Scott Cameron from University of Rochester for volunteering this month.
As always, check us out on twitter (@PERTConsortium) for more updates or with insights into how you run your PERT.
Scott James Cameron, Ph.D. M.D.
Assistant Professor of Medicine
Division of Cardiology
University of Rochester Medical Center
Key members in their PERT include:
How long has your institution had a PERT?
The UR PERT had been running in pilot mode for a few months, and was formally launched on November 1, 2016. Early in the year, we had a very pleasant woman who “failed to respond to anticoagulation for PE” present with syncope, with a truly impressive RV outflow tract mass and in right heart failure. Cardiac surgery, pulmonary medicine, cardiology, and vascular surgery rapidly communicated with each other via cell phone and made a decision that was in the best interest of the patient. The patient ultimately had a primary cardiac malignancy. It was clear that this openness in communication was the hospital’s signature of desiring the best care for the patient, and the team was formally launched shortly after.
Who participates on the PERT team?
The primary evaluation is handled by the cardiac care unit who will involve any other PERT member rapidly as needed. The University of Rochester PERT will see patients at the bedside and is comprised of twelve team members whom I call the “faithful twelve”: Emergency Medicine (1), Pulmonary Medicine (2), Cardiology (5), Cardiac Surgery (3), and Vascular Surgery (1). Interventional Radiology has also performed catheter-directed thrombolysis at our institution for some time.
How it the team activated?
The cardiac care unit is activated via the paging operator as “PERT” with the patient name, medical record number, and location in a single pager. Massive and submassive PE constitute a thrombotic emergency. The idea was to respond to PERT activations with the same urgency as a stroke or ST-Segment Elevation MI alert. We received 3 consultations in our first 24 hours, though we’re averaging around 1-2 per week.
How does the team communicate?
We mostly communicate by telephone and text. For sick patients, we’ve met by the bedside and carefully gone over the imaging data and clinical variables to make the best decision we can for the patient.
What improvements have you seen in patient care with the introduction of the PERT concept?
PE is an orphan disease which benefits from input by several medical and surgical specialties. As other PERTs realized, the main utility is that team members with a vested interest in caring for intermediate and high risk patients with PE freely communicate with each other. The prior practice was that many of us were ‘pan-consulted’, and that each consultant was free to ultimately walk away from the patient without a committed plan for patient care and disposition in place. We also made an institutional decision that all submassive PEs will have a minimum ‘step-down’ level of monitoring whereas before those patients often were admitted to general floor teams. This is in recognition of the fact that patients with submassive PE can rapidly evolve and decompensate, and so it’s important not to let one’s guard down. The interesting development at UR is that any patient with a submassive or massive PE in our ED will be admitted to the cardiology service—at least for the initial launch of the team. This was an decision made by PERT members who voiced a concern that the hospital should see a consistent team who will streamline patient care, and prevent disagreements as to who should admit the patient.
How do you see your team evolving in the future?
Dr. Sunil Prasad recently joined UR medicine as Chief of Cardiac Surgery, bringing a national reputation and expertise in mechanical cardiac assistance. We have realized that those patients with PE in extremis (cardiogenic shock with or without a contraindication to systemic thrombolysis, PEA arrest etc.) who otherwise would die may benefit from their life being ‘placed on pause’ with ECMO while ultimate treatment decisions are being made and to allow the RV time to unload. We are especially fortunate to have Dr. Neil Kumar on our team since he is a trained vascular surgeon with a secondary qualification in critical care, and can start ECMO and round on the patient each day on his ICU service. There is also room to consider surgical thrombectomy in those patients with large central PEs and RV failure.
What advice would you give to a new hospital looking to start a PERT?
Be open and honest about everything, and have the patient’s best interest at heart. When turf wars start and fiefdoms are built, it is the patient who will ultimately suffer. It’s also important to keep an open mind to new technologies, and different ways to doing things. This may be harder to achieve in large institutions where change is difficult to implement. A good strategy we found was to meet with sub-specialty physicians and proceduralists individually in the first instance, and then educate each other. This allows those with most interest to self-select, and then meet as a large group to refine treatment options. Not everybody in the hospital will see the value of PERT and this can be discouraging. Making a committed decision to have clear criteria for activating PERT and a uniform patient disposition plan are very important—especially for the ED physicians who will see most of these patients. The hardest part about PERT, we find, is making decisions on intermediate risk PE where major society guidelines appear to be purposefully vague, and less is known about the evolution of the disease. This is where PERTs nationally can come together and share patient data and perform meaningful research. It is also important to be extremely available when your colleagues need you: surgeons and physicians have very different but complimentary skillsets, and we truly are available for each other immediately at UR when there is an issue with one of our patients. Lastly, we recommend utilizing the expertise of the National PERT Consortium members. Dr. Jeffrey Kline from Indiana University has acknowledged expertise in managing PE and he is somebody I met through common basic research pursuits. Jeff provided a significant amount of clinical advice to allow the UR PERT to take off, and we’ll do that for the next person.