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Published on: September 6, 2024
Bringing PERT to Pediatrics: Initial Experience and Outcomes of a Pediatric Multidisciplinary Pulmonary Embolism
Mary P Dang1, Anna Cheng2, Jessica Garcia1
1Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Medical Center, Dallas, TX.
Insights
Establishing a pediatric pulmonary embolism response team (PERT) is feasible and improves care for pediatric PE patients. This multidisciplinary team enhances expert access and timely advanced therapies, serving as a model for pediatric PE management.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiology
- Hematology
Background:
- Multidisciplinary Pulmonary Embolism Response Teams (PERTs) are established for adults with life-threatening pulmonary embolism (PE).
- The application of PERTs in pediatrics is novel due to the rarity of pediatric PE.
- Developing a pediatric PERT paradigm for clinical, educational, and research purposes is an underutilized concept.
Purpose of the Study:
- To determine the feasibility of implementing a PERT in a pediatric setting.
- To assess whether a pediatric PERT improves the care of patients with PE.
Main Methods:
- A strategy-to-execution proposal was developed to gain institutional support for launching a pediatric PERT.
- Key stakeholders collaborated to implement the PERT.
- Patient data were collected and compared for the 2-year periods before and after PERT implementation.
Main Results:
- The pediatric PERT, led by hematology with multidisciplinary experts, took 12 months to implement.
- Analysis of 30 pre-PERT and 31 post-PERT patients showed a shift towards lower-risk PE categories post-implementation.
- Post-PERT, there was a significant decrease in time to echocardiogram and anticoagulation initiation, and a significant increase in reperfusion therapy for eligible patients.
- No differences were observed in major bleeding, mortality, or length of stay.
Conclusions:
- A pediatric PERT model was successfully established and adopted.
- The PERT enhanced access to specialists, expedited advanced therapies, and demonstrated value even for low-risk PE cases.
- This pediatric PERT serves as a potential best practice model for optimizing pediatric PE care.
Background:
Multidisciplinary pulmonary embolism response teams (PERTs) streamline care of adults with life-threatening pulmonary embolism (PE). Given rarity of pediatric PE, developing a clinical, educational, and research PERT paradigm is a novel and underused concept in pediatrics.
Research Question:
Is a PERT feasible in pediatrics, and does it improve PE care?
Study Design And Methods:
A strategy-to-execution proposal to launch a pediatric PERT was developed for institutional buy-in. Key stakeholders collectively implemented the PERT. Data were collected for the 2-year pre-PERT and post-PERT eras, and outcomes were compared.
Results:
PERT implementation took 12 months. Our PERT, led by hematology, is composed of pediatric experts in emergency medicine, critical care, interventional cardiology, anesthesiology, and interventional radiology. Data on 30 patients pre-PERT and 31 patients post-PERT were analyzed. Pre-PERT, 10% (3 of 30), 13% (4 of 30), 20% (6 of 30), and 57% (17 of 30), and post-PERT, 3% (1 of 31), 10% (3 of 31), 16% (5 of 31), and 71% (22 of 31) were categorized as high-risk, intermediate-low-risk, intermediate-high-risk, and low-risk PE, respectively. Post-PERT, there were 13 unique PERT activations. PERT was activated on all eligible patients with PE and, additionally, on four low-risk PEs. Time to echocardiogram was shorter post-PERT (4.7 vs 2 hours; P = .0147). Anticoagulation was ordered (90 vs 54 min; P = .003) and given sooner (154 vs 113 min; P = .049) post-PERT. There were no differences in time to reperfusion therapies (12 hours pre-PERT vs 8.7 hours post-PERT, P = .10). Five of six (83.3%) eligible (intermediate-high and high-risk) patients received reperfusion therapies in the post-PERT era compared to three of eight (37.5%) eligible patients in the pre-PERT era (P = .0001). There were no differences in major bleeding, mortality, or length of stay in either era.
Interpretation:
The pediatric PERT paradigm was successfully created and adopted locally. Our PERT enhanced access to experts, facilitated timely advanced therapies, and held value for low-risk PE. The University of Texas Southwestern Medical Center and Children's Medical Center pediatric PERT may serve as a best practice model for streamlining care for pediatric PE.
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