Department of Surgery, Section of Vascular Surgery, University of Kentucky Medical Center, UK HealthCare, Lexington, Ky.
Pharmacy Services, The Gill Heart and Vascular Institute, University of Kentucky Medical Center, UK HealthCare, Lexington, Ky.
J Vasc Surg Venous Lymphat Disord. 2019 Jul;7(4):493-500. doi: 10.1016/j.jvsv.2018.11.014. Epub 2019 Mar 29.
Massive and submassive pulmonary embolism (PE) can be life-threatening. Treatment options include anticoagulation, fibrinolysis, catheter-directed or open surgical thrombus removal, and extracorporeal membrane oxygenation. With increasing patient complexity and advanced therapeutic options, the approach to optimal care for patients with intermediate- to high-risk PE is not clearly established. Multidisciplinary, rapid response teams can optimize risk stratification and expedite management. A PE response team (PERT) composed of specialists from cardiology, vascular surgery, emergency medicine, pulmonary and critical care, interventional radiology, cardiac surgery, hospital medicine, and pharmacy was created at our institution. The team is tasked with evaluating and treating patients with massive and submassive PE by use of a risk stratification and treatment algorithm. We describe our initial experience with this approach.
The records of patients treated by the PERT since inception in October 2015 through May 2017 were reviewed (intervention group). The diagnoses codes of the PERT patients were retrieved from the Vizient database. A retrospective control cohort group was created using these specific diagnoses and a matching set of demographics (age, sex), Medicare Severity Diagnosis Related Group, admission severity of illness, and admission risk of mortality. Statistical analysis was performed using the Fisher exact test, the Pearson χ statistic, Student t-test, and Cochran-Cox approximation. P < .05 was considered significant.
During the time interval, 77 patients with massive or submassive PE were treated by PERT activation; 992 patients included in the control group were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of risk of mortality and severity of illness, and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower intensive care unit stay and overall length of stay. No difference was seen in direct cost between the two groups despite higher use of interventional treatment modalities in the PERT group.
In our institution, assembly of a dedicated team to treat patients with massive or submassive PE according to a clinical algorithm resulted in expedited treatment and reduced variation of care. Intensive care unit stay and overall length of stay were reduced by this approach, with no impact on direct cost despite the use of advanced modalities of treatment. We believe that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved.
大面积和次大面积肺栓塞（PE）可能危及生命。治疗选择包括抗凝、溶栓、导管引导或开放手术血栓清除以及体外膜氧合。随着患者病情复杂性和先进治疗选择的增加，对于中高危 PE 患者的最佳治疗方法尚不清楚。多学科、快速反应团队可以优化风险分层并加快管理。我们机构创建了一个由心脏病学、血管外科学、急诊医学、肺和危重病学、介入放射学、心脏外科学、医院医学和药学专家组成的肺栓塞反应团队（PERT）。该团队的任务是使用风险分层和治疗算法评估和治疗大面积和次大面积 PE 患者。我们描述了这种方法的初步经验。
回顾了 2015 年 10 月至 2017 年 5 月期间通过 PERT 治疗的患者的记录（干预组）。从 Vizient 数据库中检索 PERT 患者的诊断代码。使用这些特定诊断和一组匹配的人口统计学（年龄、性别）、医疗保险严重程度诊断相关组、入院严重程度和入院死亡率风险，创建了一个回顾性对照队列组。使用 Fisher 精确检验、Pearson χ 统计量、Student t 检验和 Cochran-Cox 逼近进行统计分析。P<0.05 被认为具有统计学意义。
在研究期间，77 名大面积或次大面积 PE 患者通过 PERT 激活进行了治疗；2013 年 10 月至 2016 年，对照组中的 992 名患者根据主治医生的判断进行了治疗，未使用该算法。两组的人口统计学特征相似，死亡率和疾病严重程度的分布相似，平均医疗保险严重程度诊断相关组权重也相似。两组的死亡率无统计学差异。PERT 组的重症监护病房停留时间和总住院时间明显缩短。尽管 PERT 组更频繁地使用介入治疗方式，但两组的直接成本无差异。
在我们机构，根据临床算法组建专门的团队治疗大面积或次大面积 PE 患者可加快治疗并减少护理的差异。通过这种方法，重症监护病房停留时间和总住院时间缩短，尽管使用了先进的治疗方式，但直接成本没有增加。我们认为，这种模式对于其他疾病实体可能具有潜在价值，特别是当涉及多个学科时。
