The Next Evolution of VTE Care

The third most common vascular diagnosis after heart attack and stroke, venous thromboembolism (VTE) can be as challenging to diagnose as it is to treat. Symptoms can present mildly and are often dismissed by doctors or attributed to other conditions. Research shows that very few patients have a strong understanding of the condition and its symptoms, often preventing many from seeking care until it is urgent — if at all.1

Increasingly understood as one of interventional care’s most glaring missed opportunities both clinically and operationally, new models are being developed to effectively capture more VTE patients before it becomes too late. On an internal review of our data from our hospital in Nashville, we determined that our Pulmonary Embolism Response Team (PERT) was assessing and treating only approximately 20% of the population with pulmonary embolism (PE), a subgroup of VTE. Knowing that PERT evaluation improves outcomes for patients, we sought to find ways to change this.

Every morning for the last three months, a group of physicians and our VTE coordinator, including myself, receive a list of patients admitted to our hospital who have been diagnosed with a pulmonary embolism along with a list of variables including lowest blood pressure, troponin level, and brain natriuretic peptide level. This allows us to quickly assess who would benefit from a PERT consult in order to determine if more aggressive care than just anticoagulation might be warranted and who, potentially, could be safely discharged, increasing our throughput in a time when beds come at a premium.

Implemented earlier this year within my team, this is just one example of new and innovative practices that have been implemented around the country to support more proactive — and ultimately effective — PE care. However, despite the benefits of multidisciplinary consultation, realizing the scope of this problem also presents many challenges that advanced technology and artificial intelligence may be key to solving.

Establishing a PERT

A concept first established in 2012 at Massachusetts General Hospital, Pulmonary Embolism Response Teams, or PERTs, are designed to help physicians better manage PE, improve care coordination, and determine the best treatment interventions for acute PE patients. Today, this interdisciplinary care model has since been formally implemented at over 100 institutions globally— and that number is only climbing.

One of the reasons this model is gaining momentum is that a growing body of research has shown that PERT team evaluation for patients not only reduces that patient’s mortality at 30-90 days, even for patients who don't receive any additional intervention, but also has a positive impact on other outcomes. Recently, Dr. Derlis Fleitas Sosa and authors completed a systematic review and meta-analysis to understand the impact of PERTs on PE management and patient outcomes, published in the European Respiratory Review.2 Sixteen studies including 3,827 patients in the PERT group and 3,967 patients in the control group were included in the meta-analysis, which found that despite the PERT group having more intermediate- and high-risk PE patients than the control group, the PERT patients had lower mortality rates. Additionally, patients evaluated by PERT teams were also more likely to receive treatment with what were considered “advanced therapies” than patients in the control group.

A Snapshot of PERT

Given this compelling case for their efficacy, what is preventing other hospitals from implementing the PERT model? As is the case with nearly any model of care delivery, the way PERT comes to life in any given hospital can depend on a multitude of factors, including the hospital type and resources available in terms of physicians, supporting medical staff, and technical infrastructure —the latter two of which we will discuss later.

Since implementing the model at my hospital several years ago, our pulmonologists have proven themselves as the hub of our PERT team, serving as the anchors at the beginning and end of the patient journey and as the quarterback during their stay. Whether patients come from the emergency department, ICU, on the floor, or an outside hospital, the pulmonologist is the first call and accepting physician — evaluating the patient on arrival and determining the appropriate care track.

In the case that our pulmonologist determines that a patient has a massive PE, the patient generally goes straight to systemic thrombolytics — and the pulmonologist can make that determination without involving others on the team because those patients need urgent care. However, for patients who can't get thrombolytics or have sub-massive PE, the pulmonologist may enlist an interventional vascular specialist (at our institution, usually an interventional cardiologist) and cardiac surgeon to evaluate the patient and determine the next best course of treatment — whether that is systemic thrombolysis, catheter-directed thrombolysis, percutaneous mechanical thrombectomy, or a surgical thromboembolectomy in the operating room.

Given that this role of clinical lead can vary from hospital to hospital and the number of team members involved is also quite variable, a new position has emerged at several centers nationally to help maximize the efficacy of the PERT model.

The Value of the VTE Coordinator

An increasingly integral member of a successful PERT team is a VTE Coordinator, an emerging position dedicated to better care strategy and process quality improvement. The VTE coordinator position was created because, despite the positive impact of the PERT model on treatment decisions, several patients that could benefit from this multidisciplinary model were still slipping through the cracks — most often because they were coming from non-traditional avenues or from other areas within the hospital.

At my hospital specifically, the VTE coordinator is an RN with cath lab experience and extensive coordination experience in cardiovascular medicine. Unlike the rest of the care team, their role is to take a more holistic view of the patient’s care and support the planning and execution in the field, whether that is offering suggestions to optimize processes and pathways, helping to identify our inefficiencies, figuring out what we're doing that may not be needed entirely, or identifying opportunities to improve our practice.

However, the VTE coordinator's role doesn’t stop once a patient receives intervention. In many cases it is also the VTE coordinator that helps us follow up with the referring physician or facility from which the patient was transferred to “close the loop,” identifies needs for further clinical care and is also often the person leading any efforts to record, study, and contribute any data and clinical research to the clinical community. If the pulmonologist is the quarterback of the PERT, the VTE coordinator is the offensive coordinator — a vital portion of our ongoing growth and success to ensure we treat as many patients as we can as optimally as possible.

The Role of Artificial Intelligence

When we think about what multidisciplinary care looks like in the future, it is impossible to not speak about the advanced tools leveraging the power of artificial intelligence (AI) to help us streamline care, boost team efficiency, and improve acute PE patient outcomes. Despite the promise that PERTs and VTE coordinators have shown in streamlining patient care, advanced technology is also showing great potential in filling in the remaining gaps.

The first area where AI is already showing promise is in improving timely detection and risk stratification— identifying PE patients and enabling physicians to prioritize their efforts. By automatically analyzing CTPA images, identifying suspected pulmonary embolism, and delivering real-time notifications to physicians, patients can be triaged faster and care teams aligned more quickly, reducing overall time to treatment.

Another area where AI shows immense potential in improving PE care is in optimizing workflow and communication, which, even with a formalized PERT program, can sometimes be a disjointed process. For example, when PERT is activated, physicians may get a page or phone call, have to find and open a computer to log into the EMR or PACS to review the CT, labs, and vitals, and then have to log into another HIPAA-compliant texting app to communicate with the rest of the care team. Platforms developed by companies like RapidAI are one example of leveraging advanced technology to further streamline and operationalize this multidisciplinary care model, better connecting physicians through one easy-to-use platform for image viewing and communication.

Finally, another area where AI holds great promise is in connecting the loop of patient care and integration into the EMR. Research shows that of those who experience and survive a PE, one-third will have a recurrence within 10 years.3 Integrating workflow apps with the EMR can not only play an important role in giving responding physicians more information about a patient’s current clinical presentation as well as their history in determining their treatment path, but also by improving the opportunities to ensure appropriate patient follow-up after discharge.

As PERT programs and VTE coordinators continue to increase in popularity, and AI-enabled technologies continue to become more capable and more widely available, the two combined hold enormous potential for not only complementing, supporting, and enhancing physician processes but also truly optimizing VTE care and improving patient outcomes.

It is incredibly exciting to see how AI plays a role in the advancement of this field, ensuring that all patients are identified and treated in order to more efficiently and effectively improve symptoms and extend life. V