Pulmonary embolism is the third leading cause of cardiovascular death in the United States. It starts with a blot clot that commonly forms in the leg, migrates through the heart, and settles into an artery in the lungs. A pulmonary embolism can cause serious problems with breathing, enlarge the right side of the heart and also result in death.
While pulmonary embolism is hardly a household word, PE and related blood clots (DVT and VTE) kill some 100,000 Americans each year. They often arise after sitting in cramped conditions for hours, such as long flights. In 2003, well-known NBC journalist David Bloom died from a pulmonary embolism after spending extended time crouched inside armored vehicles while covering the Iraq War.
Some patients “have all these crazy (heart) rhythms from it and ultimately develop heart failure from the strain placed on the right heart,” said nurse Erin Lambert, heart failure program manager at New Hanover Regional Medical Center in Wilmington.
Though women are more susceptible, pulmonary embolisms can attack anyone. Sometimes patients come to the emergency department for another reason and physicians uncover a clot in the leg or lungs. Clots can develop after surgery. Lambert saw one 28-year-old woman whose hormonal birth control likely triggered a clot.
You might assume such a serious ailment would have a standard course of treatment in U.S. hospitals. But treatment has largely depended upon who makes the diagnosis, according to interventional cardiologist Dr. Lance Lewis with Novant Health Heart & Vascular Institute in Wilmington. It might be a cardiologist, pulmonologist, vascular surgeon, hospitalist or another specialist and “everybody had their own way of treating it," he said.
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What’s more, until a few years ago, new treatments had stalled. “This is one of the leading killers in the United States,” Lewis pointed out, but “the needle had not moved on how well people do with this in decades.”
Lewis and Lambert – colleagues at New Hanover Regional Medical Center – wanted to do more. They ended up creating the Pulmonary Embolism Response Team (PERT) – and a new process to care for PE patients that leads to better outcomes.
Today, it’s getting national attention. PERT standardizes treatment, incorporates an exciting and relatively new treatment option, and keeps patients closer to home.
Thrombectomy: removing out the clot
Like-minded physicians have advocated for years for a standard treatment protocol for pulmonary embolism.
Inspired to develop a model for their hospital, Lewis and Lambert began by studying what other hospital systems were doing. Then, in a marathon four-hour session, they crafted what looks like an elaborate flow chart. It outlines “if-this, then-that” scenarios for all types of pulmonary embolisms, from those which can be treated at home to life-threatening, get-it-out-now clots.
Lewis and Lambert brought their draft to the eight other interventional cardiologists at the hospital. They helped refine it. Lambert also sought champions for the new process in the cath lab, emergency department and other areas of the hospital that encounter PE patients.
The severity of the clot and the amount of strain on the heart help dictate the correct course of action in the PERT model. Physicians use several tools for diagnosis. They include biomarkers, or substances in the body which indicate illness or infection, computerized tomography (CT) scans, and echocardiograms.
Intermediate patients can benefit from a thrombectomy, the novel treatment which Lewis calls a “game changer,” available only in the last several years.
During a thrombectomy, “we take large-bore catheters up into the lungs through the heart and suck out the clot," Lewis explained. The procedure requires an appropriately sized catheter that’s also “soft and malleable enough for us to manipulate through the heart safely.”
In many high-risk patients, powerful clot-busting medications called thrombolytics are given with the goal of making the clot dissolve quickly.
A thrombectomy might follow. Low-risk patients can take blood-thinning drugs at home. All patients need anticoagulation medication after treatment to help ensure a clot doesn’t come back.
Caring for patients closer to home
PERT launched in March 2022. Over nine months, the PERT team treated an average of three patients a week using the new protocol. The results:
- They reduced the typical length of stay in the hospital by more than a day.
- Saw far fewer readmissions.
- Provided better quality of life for patients.
Previously, New Hanover referred some pulmonary embolism patients to UNC Health, which has been a strong partner, Lewis said. With the new model, the PERT team is treating more patients at New Hanover, close to friends and family. Other healthcare systems in the area are now referring pulmonary embolism patients to New Hanover. WilmingtonBiz named Lewis and Lambert among its Health Care Heroes.
Word of the PERT team’s success has spread. Hospitals in Georgia, Florida and Virginia have contacted Lambert for more information. Lambert was invited to present the team’s work nationally at the American College of Cardiology Quality Summit, which focuses on tools and best practices for cardiology care.
The hospital was also one of two in North Carolina invited to join a clinical trial to compare the results of thrombectomy to other forms of care. Patients will be studied before and after treatment. Lewis is excited to gain data that can be used to refine and strengthen the PERT model.
All this news is heartening for anyone in the region who needs to be treated for pulmonary embolism. But what if you want to avoid one?
Consider Lambert’s patient who developed a clot after sitting for hours at a time on biweekly flights to and from California. Too much sitting and lying down isn’t ideal even in the hospital after surgery. Start taking a few steps as soon as your physician indicates you’re ready.
Lambert summarizes her advice in four life-enhancing words: “Get up and move.”