Singapore General Hospital’s new rapid-response service aims to expedite critical medical decisions and treatment logistics for patients with severe pulmonary embolism to achieve better health outcomes.

Pulmonary embolism (PE), one of the most common complications seen in hospitals, can kill if not identified and treated promptly.

As such, a new Singapore General Hospital (SGH) service has been created to provide fast and coordinated care to ensure better health outcomes for patients with acute PE or blood clot in the lung. “Pulmonary Embolism Response Team (PERT) is a rapid-response team with multiple specialists to expedite the decisions, diagnoses and logistical planning for very sick PE patients,” said Dr Kristen Alexa Lee, Consultant, Department of Vascular and Interventional Radiology, SGH.

PE occurs when a blood clot develops in a blood vessel, often in the veins of the legs, and travels to a lung (pulmonary) artery, where it can block blood supply to the lungs. Significant blockage can lead to low oxygen levels, pressure buildup in the right side of the heart and, in severe cases, death. “PE is often called a silent killer because, when caught too late, patients may develop cardiac arrest and pass away. Our aim is to pick it up beforehand, as PE is highly treatable and preventable,” said Dr Cheong May Anne, Associate Consultant, Department of Haematology, SGH.

<<“PE is often called a silent killer because, when caught too late, patients may develop cardiac arrest and pass away,” says Dr Cheong May Anne (centre), seen here with two other members of the PERT team: (left) Dr Ho Vui Kian, Senior Consultant and Head, Intensive Care Medicine, SGH; and Dr Mathew Jose Chakaramakkil, Consultant, Cardiothoracic Surgery, SingHealth.>>

This multidisciplinary initiative has a core team staffed by specialists in respiratory and critical care, anaesthesiology, interventional radiology, cardiothoracic surgery, haematology and cardiology.

The roles of each specialty come into play the moment a patient arrives at the hospital, all the way to discharge. First, the critical care specialists manage the overall clinical picture of the patient when he displays PE symptoms, such as breathlessness. They stabilise his condition, check for PE through a computed tomography (CT) scan and look for signs of right heart dysfunction (when the heart’s right ventricle is too weak to pump enough blood to the lungs).

For patients with PE and concerns of right heart dysfunction, PERT is activated. This requires the core team to convene on a secure hospital group chat to discuss imaging and laboratory findings as well as treatment options. Haematologists provide expertise on medications, such as blood thinners. Interventional radiologists and cardiothoracic surgeons offer interventions to expedite removal of blood clot from the lungs. Interventional radiologists place catheters, under image guidance, through a small incision in the groin or neck into the pulmonary arteries. Clot-busting agents are then given directly to break down the clot. Special suction devices can also be placed in the clogged arteries in a similar fashion to suck out clots.

The PERT service also ensures the long-term care and management of patients. Following discharge, patients are referred to other SGH services such as the thrombosis outpatient clinic for follow-up.

The reduced time taken for communication among the specialists involved in treating severe PE and coordination of patient logistics means taking advantage of the critical window of time for prompt and early treatment before the tide turns. “A common scenario before PERT was established was that a surgeon had to talk to five different groups of people for the different types of interventions. During this process, there may be gaps in coordination and fragmentation of care. A consolidated multidisciplinary management is essential and that is the concept of a PE response team,” said Dr Cheong.

Individualised care

Since its formalisation in November 2021, PERT has been activated more than 70 times.

The increasing incidence of PE that the hospital sees is due to Singapore’s ageing population, a surge in cancer-related blood clot blockages and, more recently, patients with COVID-19 that place them at a higher risk for the condition. “The fact that this team is multidisciplinary means many different eyes and perspectives come together to give the best personalised care to the patient,” said Dr Cheong.

The next phase for PERT is to ensure awareness of the service across various disciplines at SGH such that all patients can receive timely care when severe PE is diagnosed. Engagement of teams caring for cancer patients and post-surgical patients is essential as these patients are at a higher risk of developing blood clots.

A longer-term goal is to develop a seamless healthcare experience between hospitals for enhanced patient care. “As PE patients can come from different healthcare clusters and hospitals, we hope to provide the highest level of care through harmonisation across institutions and offer PE care in a seamless and personalised manner,” said Dr Lee.

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