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PERT Activations
Per Annum
25
20
18
This chart shows all activations of the PERT program from
its inception in October 2012 through December 2014
(FY13—early FY15). This encompasses 351 total activations
over 26 months. Utilization of PERT has consistently exceeded
18
17
17
15
14
expectations, confirming an underlying need for such a rapid
response service to treat patients with pulmonary embolism.
20
19
10
10
13
12
6
5
13
13
11
10
5
4
17
14
12
8
6
17
13
10
0
OCT
Source: Massachusetts General Hospital PERT program.
NOV
DEC JAN
FEB MAR APR MAY JUN
FY13
FY14
JUL AUG SEPT
FY15
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Boston, MA 02114
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PAID
MASSACHUSETTS
GENERAL HOSPITAL
An Interdisciplinary
Approach to the
Treatment of
Pulmonary Embolism
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A long-term evaluation of patient
outcomes will promote evidencebased treatment protocols
Rapid response team offers a
coordinated institutional approach
across specializations
For More Information
( 617-724-7739
8 [email protected]
massgeneral.org/PERT
Pulmonary Embolism
Rapid Response Team
(PERT)
Computed tomography (CT)
scans showing a clot in the main
pulmonary trunk extending to
both main pulmonary arteries
that obstructs blood flow to the
lungs (left), and a cross-section
of a clot (arrow) in the right
ventricle indicating that there is
still a clot “in transit,” migrating through the heart chambers
toward the pulmonary arteries
(right).
Pulmonary emboli (PE) are
the most common reason
for in-hospital deaths in
the U.S., occurring at a rate
of more than 100,000 per
year. Yet optimal treatment
has not been systematically studied. Up to 30 percent of PE have high-risk features:
hemodynamic instability, right ventricular dysfunction, or evidence of myocardial
necrosis. About 10 percent of PE are fatal within an hour of the onset of symptoms;
untreated cases have a 30 percent mortality rate.1 A major hindrance in improving
Channick, MD, director of the Pulmonary Hypertension Program and an expert
outcomes is that patients may present in many hospital departments, and treatment
in chronic PE; Christopher Kabrhel, MD, MPH, director of the Center for Vascular
decisions are determined by clinical expertise and medical or surgical resources
Emergencies in the Department of Emergency Medicine; and Rachel Rosovsky, MD,
in that department, without a unified, evidence-based approach. In October 2012,
an expert in clotting disorders.
Massachusetts General Hospital initiated a multidisciplinary rapid response program
PERT incorporates treatment perspectives from specialists in cardiology,
called PERT, for Pulmonary Embolism Response Team, a collaboration focused on
cardiothoracic surgery, echocardiography, emergency medicine, hematology,
improving the care of patients with massive or submassive pulmonary embolism. This
pulmonary/critical care, radiology, and vascular medicine and intervention. After
initiative will also collect data on outcomes in order to enhance knowledge about PE
two years, PERT team members report a more coordinated institutional approach
and to better inform therapeutic decisions in the future.
to this highly prevalent, life-threatening disease, with treatment tailored to the
PROMOTING AN EVIDENCE-BASED APPROACH
individual patient, based on degree of hemodynamic and cardiopulmonary
instability as well as other parameters.
Treatment decisions for PE include both existing therapies and novel approaches.
Longer term, PERT is enabling the systematic evaluation of multiple approaches
Open surgery to remove the clot is one of many treatment alternatives; others
and techniques that will promote scientific learning and evidence-based research.
include anticoagulation, systemic intravenous thrombolysis, locally delivered
To advance the science of PE care, PERT is developing treatment protocols and
thrombolytics, thrombo-aspiration and mechanical thrombectomy. Each of these
is maintaining a robust registry of patients, with a database of treatments and
strategies has the potential to improve patient outcomes. Comparative data
outcomes. The program has begun a multidisciplinary follow-up clinic to collect
regarding which therapy is best for a given patient with PE, however, is sparse, and
long-term patient outcomes and is planning further studies.
2
existing guidelines provide only general advice.
To address the need to streamline complex treatment decisions about individual
PERT ACTIVATION AND OUTREACH
patients while incorporating expertise from multiple disciplines, a Mass General team
PERT is activated by a single phone call from any referring physician within Mass
coalesced to create PERT. This initiative, which involves more than seven departments
General. Following a "rapid response" consultation, an online meeting of the
that share a common interest in PE, has been led by Kenneth Rosenfield, MD, section
multidisciplinary team is convened. Team members discuss the case and treatment
head for Vascular Medicine and Intervention; Michael Jaff, DO, director of the MGH
options while reviewing radiographic images, lab results and clinical notes in
Fireman Vascular Center, an expert in deep vein thrombosis and lead author of the
real time. Referring physicians often participate in the discussion. After reaching
AHA guidelines document on the subject of PE; Thoralf Sundt, MD, chief of cardiac
consensus regarding the best response, the PERT system activates appropriate
surgery and co-director of the MGH Corrigan Minehan Heart Center; Richard
hospital resources to rapidly implement an integrated care plan.
Finally, in response to the interest that PERT has generated among physicians
around the country, the Mass General team is forming a collaborative national
PERT Activations, October 2012 Launch–December 2014
The most common
treatment after
PERT activation
by consensus was
anticoagulation
alone (60.7%). Other
procedures were also
provided. Long-term
outcome data will
enable increasingly
informed decisionmaking.
Source: Massachusetts General Hospital PERT program.
network of Pulmonary Embolism Response teams. That consortium, to be
293 INTERVENTIONS:
60.7% Anticoagulation only
20.8% IVC filters
8.7% Catheter-direct thrombolysis
4.0% Surgery
2.7% IV lysis
2.3% ECMO
launched at a spring 2015 meeting at MGH, will provide further opportunities to
evaluate new treatment algorithms and ideas arising from PERT’s coordinated
multidisciplinary program. PERT leaders are committed to advancing the field
more rapidly to benefit patients. ■
1
P rovias, Tim, David M. Dudzinski, Michael R. Jaff, Kenneth Rosenfield, Richard Channick, Joshua Baker, Ido Weinberg, et
al. “The Massachusetts General Hospital Pulmonary Embolism Response Team (MGH PERT): Creation of a Multidisciplinary
Program to Improve Care of Patients with Massive and Submassive Pulmonary Embolism.” Hospital Practice (1995),
February 2014, 42 (1) : 31–37.
2
J aff, Michael R., M. Sean McMurtry, Stephen L. Archer, Mary Cushman, Neil Goldenberg, Samuel Z. Goldhaber, J. Stephen
Jenkins, et al. “Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and
Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement from the American Heart Association.” Circulation,
no. 16 (April 26, 2011): 1788–1830.
0.7% Vortex
MALE: 56.1% FEMALE: 43.9%
AGE RANGE: 10–98 yrs., median 62 yrs.
SURVIVAL TO DISCHARGE: 85.3%