Initiation of a Multidisciplinary, Rapid Response Team to Massive and Submassive Pulmonary Embolism

https://doi.org/10.1016/j.amjcard.2017.07.033Get rights and content

Pulmonary embolism (PE) can result in rapid clinical decompensation in many patients. With increasing patient complexity and advanced treatment options for PE, multidisciplinary, rapid response teams can optimize risk stratification and expedite management strategies. The Massive And Submassive Clot On-call Team (MASCOT) was created at our institution, which comprised specialists from cardiology, pulmonology, hematology, interventional radiology, and cardiac surgery. MASCOT offers rapid consultation 24 hours a day with a web-based conference call to review patient data and discuss management of patients with high-risk PE. We reviewed patient data collected from MASCOT's registry to analyze patient clinical characteristics and outcomes and describe the composition and operation of the team. Between August 2015 and September 2016, MASCOT evaluated 72 patients. Seventy of the 72 patients were admitted to our institution, accounting for 32% of all patients discharged with a primary diagnosis of PE. Average age was 62 ± 17 years with a female predominance (63%). Active malignancy (31%), recent surgery or trauma (21%), and recent hospitalization (24%) were common. PE clinical severity was massive in 16% and submassive in 83%. Patients were managed with anticoagulation alone in 65% (n = 46), systemic fibrinolysis in 11% (n = 8), catheter-directed therapy in 18% (n = 13), extracorporeal membrane oxygenation in 3% (n = 2), and an inferior vena cava filter was placed in 15% (n = 11). Thirteen percent (n = 9) experienced a major bleed with no intracranial hemorrhage. Survival to discharge was 89% (64% with massive PE and 93% with submassive PE). In conclusion, multidisciplinary, rapid response PE teams offer a unique coordinated approach to patient care.

Section snippets

Methods

MASCOT was formed at Beth Israel Deaconess Medical Center (BIDMC) to include experts in thrombosis, critical care, cardiogenic shock, and catheter-based interventions employed in acute massive and submassive PE. The team comprised subspecialists from cardiology, pulmonology, hematology, interventional radiology, and cardiac surgery. A virtual pager was created that can be accessed through the paging directory throughout the BIDMC and affiliated hospital network and is integrated into the BIDMC

Results

MASCOT was formed in August 2015 and formally evaluated 72 patients through September 2016. Virtual consultation occurred in 2 patients who were at an outside facility and were successfully managed at the referring institution by mutual agreement. Of the remaining 70 patients whom we evaluated at our institution, 37 (53%) had been transferred from an outside facility with a known or presumed diagnosis of PE. Consult requests originated from the ED in 49%, with the remainder from inpatient

Discussion

We describe logistics and initial experience of a multidisciplinary, rapid response PE team focused on high-risk PE. We demonstrate steady utilization over the first 14-month study period. We also describe the clinical characteristics of the high-risk PE population evaluated by the team, along with treatment strategies and in-hospital outcomes.

After its formation, MASCOT quickly became a well-recognized and employed consultative resource throughout the hospital, particularly by the ED. The

Acknowledgment

The authors thank Larry Nathanson, MD, for accumulating ED consult request data, and Stephanie Li for assistance in collection of ICD data.

Disclosures

Dr. Bauer reports consulting for Boehringer Ingelheim and Janssen. All remaining authors report no pertinent disclosures.

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