Thank you heather. I have no potential or actual conflicts of interest. However have a tremendous personal bias in favor of this program. Uh And lastly it's a great pleasure to present on behalf of my colleagues in the room which are collectively part of the Pert team. So are aspects of Pert here. Support stands for pulmonary embolism response team. What are the unique aspects of our program? Well, number one, there's a unified approach to pulmonary embolism evidence based care and this is part of a national movement. However, we are unique in that we not only provide services for a single institution but also look at the whole system to helpfully revolutionize a system based approach which both includes state of the art care as well as resource allocation, is quality and data driven. And we have initial publications which suggests improved outcomes which were the first papers to our recollection to ever suggest that as well as predictive factors for intervention in the setting of pulmonary embolism. And lastly this provides a platform for both research education deepening experience and that's evidenced by current ongoing trials and some that will be present soon, which I'll close with and talk about it in a little bit. So pulmonary embolism, what is this again? It's a pulmonary embolism response team. How do we activate it? It's activated through the uh call through our transfer center and it's meant to access patients who are generally more ill as evidenced by any one of a number of scoring systems which suggests poor outcome in the setting of pulmonary embolism. Uh It also is activated when we have outside transfers which request I. C. U. R. E. D. Transfer. Our members are available 24 73 65 and consists of a multidisciplinary team, all of which are sitting in this office uh collectively so pulmonary M. ICU attendings and fellows, a pulmonary vascular attending the vascular medicine, attendings interventional cardiology attendings of a sub special group that also participate in indirect intervention of pulmonary embolism. And see see I I see you fellows and attendings as relevant for transfer and care. What happens? This is a real time virtual review. Uh Everyone is on the phone reviewing the data, reviewing the case, interacting with the referring physicians and looking for a consensus plan for initial management observation as well as contingent plans and the benefits of a per program. Again this is part of a national movement but I think the way we enter inter digit eight the system and how we implement it here is transformative. The benefits are to standardize care, be able to rapidly mobilize resources for prompt intervention, especially in patients with shock or near shock. Be able to provide again the platform for dissemination of experience, education and research and hopefully improve outcome. I mentioned this was data driven and since the inception in 2019 at the end of November we had 597 and in the first few days we kind of blew well past that so we're now well over 600 activations from the service since intervention. And you can see um in the last six months we've had a very sharp uptick which we're looking into the first few. I just thought, well maybe it's a blip. Well maybe it's another blip. It's not a blip. This is real. This is a great example of a system level. How we can evaluate data by this is transferred. One of the measures of and one of the recommendations we have are their patients that may not that are either actually in shock or a problem requiring a higher level of care or potentially in shock, requiring a higher level of care that may not be available at all institutions throughout our system. So again the orange lines are those patients who are transferred the blue lines are those that stay in place. And we at least to date have about half of the patients that we see. We do nothing other than confirmed the plans of staying in place, treating with anti coagulation and so forth. But again, looking for those patients that may be at risk potentially ill. I'm fond of saying sneaky sick that deserve a higher level of care is also one of the goals of the per team. So again, data driven and this is these are two examples of dozens of data cuts that we look at and have the option to look at. Part of those data cuts. Then led to two publications from our initial experience. And I'd like to share those very very briefly with you. The first is our description of our first uh 9 to 12 months of experience and it had a unique twist to it. So this was a prospective collection of data of all patients admitted to U. H. C. M. C. Many per reproach reports only stayed well we got called 60 times and here's what we did. But this actually looked at every single person that was admitted or had to carry the diagnosis of pulmonary embolism. And then we compared what happened to the people on whom we were called versus what happened to the people that we were not called about. This. This was a unique opportunity. And we were able to look at our procedure utilization our outcomes patient characteristics and also assessment of risk of either deterioration or needing advanced therapies. And so these were compared using propensity propensity matched cohorts. A summary of the interventions then uh upon people that we are not called uh interventions or advanced interventions and by interventions. I mean, advanced interventions being on uh anti coagulation and or routine placement of an Ibc filter in patients who could not receive anti coagulation. And these interventions included catheter based thrown back to me, T. P. A catheter based ultrasound tp, a license surgical from Becht Amis. And I can I'm proud to say ECMO cases were over a half a dozen ECMO cases, all of which have left the hospital ah breathing. So that's again a really real testament to the skill of page of our team. Um Again, about a third of the patients of our initial, Approximately 200 patients that upon which we recalled received one of these interventions interestingly when we looked at the predictive formulas or the typical predictive formulas, which looked at the risk of people. Pesky score or the pulmonary embolism severity index is something that tells us approximately the risk of subsequent bad outcome within one month. And we found that traditional measures of severity were not as predictive of people that were results, were receiving interventions. And this was an important finding similarly, which is a very interesting aspect and something which we hope to deepen throughout the system in which we're working very carefully on is not only the acute care of pulmonary embolism, but subsequent care certainly a lot of the secret of good outcomes and pulmonary embolism is to make sure of longitudinal follow up for both complications and adequate duration of anti coagulation and this is critically important. And it suggested that the patients in which we were called and entrained in the system had almost twice as many follow ups. Uh, and this is I think really a key to the future of pulmonary embolism care and it's starting to be reflective in both the american society for hematology guidelines as well as part guidelines for long term follow up, most importantly though, this is a busy slide but what I want to call your attention to is that when we compared the patients that we were called on to the patients that we are not called on, we found out that composite endpoints including major problems including death, all cause mortality, major bleeding. Readmission rates were significantly lower in patients upon which we were called versus those that were not and this was both with and without matching. So the raw data un selected as well as matching patients who looked alike. So this was the first to our knowledge, suggestion that pulmonary embolism response teams could be of value in improving patient outcome, extending our data. Then we looked at this represents a second paper published last year that predicted are both the factors that caused activation and those that subsequently led to interaction. And so with these in mind, we initially attempted to construct a scoring system which I'll show you and then applied the scoring system into the ladder bottom line. So we were able to look at the patients that we activated on and those patients that potentially we should have or could have been activated on based on our scoring. Secondly, we looked at patients upon whom we performed an intervention and compared those two patients that potentially looked just like those patients but did not receive an intervention. And so this was yet another way to get at the fact of how useful was our intervention, was it helping people. And so what we found in just the raw determination of these factors that physiologic and morphological factors relating to pulmonary embolism were important in looking at both of the patients who ultimately received advanced therapies. And so our scoring system looked at either a composite physiologic score, looking at any of the physiologic parameters as well as a marker of RV two lb ratio or right ventricular strain. And you can see that About 50% of the patients with a score of two or more received intervention, while less than about 7% of those with only one received intervention If we took and looked at these theoretical populations then and looked at both 30 and 90 day data, we compared patients who upon whom we were called and intervened versus those that we probably should have, but look just like it, but we weren't called. And in point of fact, I'd like to draw your attention to the line. The blue line is our patients that we Uh that we consulted on. The red line is not so mortality. Uh, we had a mortality of almost 20% upon in patients that were not called on zero. In those we were major bleeding was similar, but readmission less much less so and this was true, both at 30 and 90 days. So to reiterate the transformative aspects of ruh per team. Certainly we have the unified approach to care for pulmonary embolism rapidly mobilized responses and hopefully change care. This is a system based intervention as well. And so that provides a unique aspect to serve our patients in Northeast Ohio as well as a few referrals from outside the state. This is quality and data driven and our initial publications provide unique and special insights into the experience and treatment of pulmonary embolism as well as predicting the need for response. And these initial papers and perspectives have now formed the always planned on platform of research, including landing natural national studies like the High place to study. Looking at a very interesting study which were in the process of moving forward with now to use artificial intelligence as a parallel way to decide who should be intervened upon. What should we do with pulmonary embolism. And lastly participating in a number of registry studies which help us learn more about the interventions that we're doing. I'd like to really thank all the members of the per team that are in the room and I would really appreciate the opportunity to present on behalf of our team. Thank you heather
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