Experience at University Hospitals Cleveland Medical Center Shows Effectiveness of Pulmonary Embolism Response Team Approach

PERT members also launching clinical trials of new interventional devices, studying use of artificial intelligence

Innovations in Pulmology & Sleep Medicine and Innovations in Cardiovascular Medicine & Surgery | Winter 2023

The Pulmonary Embolism Response Team (PERT) at University Hospitals Harrington Heart & Vascular Institute, formed just five years ago as a multidisciplinary group of specialists to provide rapid, real-time consultation and collaboration to better manage pulmonary embolism (PE) patients, is generating new evidence on the success of the approach, even at a large and complex multi-hospital health system like University Hospitals (UH).

Robert J. Schilz, DO, PhD

Jun Li, MD

A prospective study of 220 PE patients treated at UH system hospitals, published by the UH PERT specialists in the Journal of Invasive Cardiology, shows that those patients where the primary care team activated PERT had significantly better outcomes in terms of readmissions, major bleeding and mortality than those for whom PERT was not activated. Patients managed by PERT were also more likely to undergo advanced therapies for the PE than were other patients, such as large-bore thrombectomy to remove the clot.

“This is among the first data that's ever been published showing that PERT actually leads to better outcomes,” says Robert J. Schilz, DO, PhD, Director of the Pulmonary Vascular Disease Program in UH Cleveland Medical Center’s Division of Pulmonary, Critical Care and Sleep Medicine and a member of the UH PERT.

Such results from a multi-hospital system like UH are important in the ongoing adoption of the PERT concept and PERT protocols, says Jun Li, MD, an interventional cardiologist within UH Harrington Heart & Vascular Institute and a member of the UH PERT.

“The PERT concept came from Massachusetts General Hospital many years ago, but it is more of a solo hospital,” she says. “At our institution, there was a unique opportunity to study the hub-and-spoke model when it comes to PERT, because we have so many individual hospitals involved. We were the first ones to publish on the effectiveness of PERT in a healthcare system like ours.”

The UH Experience

At UH, the PERT consists of specialists from cardiology, interventional cardiology, pulmonary and critical care medicine, vascular medicine, cardiothoracic surgery. Since the inception of the program, UH PERT has had more than 1,000 activations, whereby patients who urgently require specialized multi-disciplinary team approach are assessed real-time.

The UH team has also documented the success of its PERT program in treating some of its most severely ill patients – those with a massive or high-risk PE who were stabilized with extracorporeal membrane oxygenation (ECMO) before undergoing a large-bore thrombectomy to remove the clot. In a case series published in the journal Catheterization and Cardiovascular Interventions, the team reports that while six of nine of these patients had cardiac arrest before therapy, mortality in the 90-day follow-up period was 22 percent, leading them to conclude that ECMO in combination with large-bore thrombectomy is a viable treatment option for patients with significant hemodynamic compromise.

“It was a staged approach of stabilization with ECMO, and then employment of an advanced catheter-based technique, and many patients did well,” Dr. Schilz says. “This type of PE was something that would have killed almost all of them. We have very solid experience with this approach, and it’s very successful in a very ill group of patients.”

Focus on Continuous Improvement

Because PE is so often life-threatening, the UH specialists that make up PERT are constantly looking for ways to improve outcomes for patients. Dr. Li and the PERT team, for example, are conducting two new clinical trials at UH Harrington Heart and Vascular Institute, evaluating the next generation of devices for large bore thrombectomy.

“There are a lot of new technology being developed, and these devices may make the process more efficient,” she says. “We’re always trying to find things that might improve the process and improve outcomes for patients.”

Clarifying the role of AI

Dr. Li is also leading a soon-to-launch investigator-initiated study of artificial intelligence (AI) technology and its potential to flag worrisome PEs and thereby speed up the response time of PERT. Although some hospitals have already implemented AI in this way, there isn’t yet much evidence to support it one way or the other, she says.

“AI is a FDA-approved mechanism to identify large burden PEs,” she says. “However, it really hasn’t been fully studied yet. We know it can be done, but whether it makes a difference in outcomes is still unclear – such as efficiency of activation of PERT, decreasing the amount of time to the patient being discussed by the team or providing a definitive therapy for the patient. We hope this new study will provide some of those answers.”

However, given its track record in helping to identify strokes, Dr. Li says she’s hopeful AI has a role to play with PE.

“If there’s a way for AI in the background to continually analyze studies and flag the radiologist or the PERT team for a PE patient with significant clot burden that needs to be discussed, I expect it’s going to cut our activation time dramatically,” she says. “Being more efficient and systematic will help us deliver the appropriate care to the appropriate patient.”

Dr. Schilz agrees.

“There are ways that you can use artificial reading intelligence and match that with available physiologic data like heart rate, blood pressure and oxygen needs, which can be gleaned from the electronic medical record,” he says. “When you marry these two together, that might be a useful tool to help aid in risk stratifying patients with serious pulmonary embolism. It’s an additional layer of identifying patients that may be at risk for adverse outcome. Given how well developed our PERT program is, along with the ability to engage high levels of thoracic imaging, we're in a great position to explore this and to see whether it can be useful.”

Contributing Experts:

Robert J. Schilz, DO, PhD
Director, Pulmonary Vascular Disease Program
University Hospitals Cleveland Medical Center
Associate Professor, Case Western Reserve University School of Medicine

Jun Li, MD
Interventional Cardiologist
University Hospitals Harrington Heart & Vascular Institute
Clinical Assistant Professor, Case Western Reserve University School of Medicine