Abstract Rationale Administration of systemic thrombolysis (ST) in patients with massive and high-risk submassive pulmonary embolism (PE) requires expertise and resources often unavailable at regional hospitals. Challenges associated with transfer to a referral center include limited bed availability and risk of clinical decompensation. Remote intensivist consultations (tele-ICU) are common at centers without on-site critical care support, but reports on outcomes of PE patients treated with ST under tele-ICU direction are lacking. Methods A retrospective cohort study evaluated adult PE patients treated with ST at regional hospitals within a single care system between January 2024 and September 2025. The tele-intensivist and on-site providers had access to PE management protocols developed by the multidisciplinary team at the referral hospital. All patients received ST with a 10 mg intravenous alteplase bolus followed by 40 mg over 2 hours. Outcomes were evaluated by transfer status using Fisher’s exact test or the Kruskal-Wallis test. Results 35 PE patients received ST at seven regional hospitals. Median age was 63 years, 57.1% were female, 25.7% had massive, and 74.3% had submassive PE. Elevated troponin was noted in 94.3%, elevated BNP in 90.3%, lactic acidosis in 40.6%, and right ventricular dysfunction by CT or echocardiography in 97.1%. The most common reasons for ST were clinical instability or risk of clinical decompensation. In-hospital mortality was 2.9%. Escalation of care was required in three cases: an additional 50 mg of alteplase resulting in resolution of hypotension; initiation of VA ECMO followed by successful decannulation; and catheter-directed embolectomy due to increased clot burden. There was one hemorrhagic complication, a lower extremity hematoma following a fall, requiring fasciotomy. Following ST administration, 24 patients were transferred to the referral hospital while 11 remained at regional hospitals with clinical improvement cited as the most common reason. There were more patients with massive PE, lactic acidosis, and lower blood pressure among those transferred, but there were no differences between the groups in escalation of care, length of stay, in-hospital mortality, discharge destination, or readmissions (Table 1). Conclusions Administration of ST to PE patients under the direction of the tele-intensivist appears safe, provides a treatment option when immediate patient transfer to the referral center is not possible, and allows selected patients with a stable clinical course to remain at their local hospital. Adherence to clinical protocols and close coordination of all treatment team members are necessary to optimize outcomes and minimize complications. This abstract is funded by: Allina Health Foundation
Abelson et al. (Fri,) studied this question.