Community Hospital Offers Catheter-Directed Thrombolysis

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.