Improving the Hospital Transfer Process for Acute Type A Aortic Dissections

Abstract

Patients with acute type A aortic dissection who arrive at hospitals that lack the facilities to treat them must be transferred to a tertiary care facility to receive treatment. The transfer process involves a checkpoint at which the transfer is accepted or denied. Delays in making this decision may lead to suboptimal health outcomes. In light of this, the goal of this project was to devise a way to reduce the time to decision of transfer requests for patients with an acute type A aortic dissection. The project followed the Define-Measure-Analyze-Improve-Control (DMAIC) approach. To better understand the process, data were obtained from the University of Texas Southwestern Medical Center regarding reasons for patient transfer cancellation and the average time until a transfer was denied or accepted. After data analysis, a fishbone diagram was used to display 23 root causes of the delays in time to decision of the transfer request. These were narrowed down to the following four significant causes using a nominal voting technique: (1) no standard on disease-specific information for the handoff, (2) lack of a real-time database, (3) incompatible electronic health record system between facilities, and (4) multiple communication handoffs causing confusion. Solutions to each root cause were evaluated using a solution selection matrix. The final two solutions proposed for implementation were as follows: (1) to establish checklists of required documents and patient transfer criteria and (2) to create a regional database to provide real-time information on hospital capacity.

Quality of inter-facility transfer for Type A aortic dissection patients in a medical center in Taiwan: a retrospective observational study

“…This study aimed to assess the quality of care of patients with type A AD who underwent inter-facility transfer [12,13,18]. The control group had significantly higher percentages of vital signs out of the target range after the transfer, with 96.2% at the receiving hospital's triage and 72.1% starting hemodynamic management promptly upon arrival.…”

“…This result implied that most patients with type A AD received inadequate hemodynamic management at the transferring hospital. From the perspective of transfer safety [16,18,21], inadequate hemodynamic management before transfer could have adverse effects on inter-facility safety, such as accelerating the progression of type A AD due to persistently uncontrolled SBP and HR [12]. The transfer staff should request the transferring hospital to provide better hemodynamic management before transfer [16].…”

“…Our recommendation is that ambulance staff should possess the capability to manage critical conditions beyond simply titrating oxygen supply (e.g., transitioning from nasal cannula to mask use). Performing routine intubation before transferring to target hospital is not always necessary [13,23], but for the sake of patient safety, when there is a possibility of respiratory failure, ambulance staff should be equipped with the ability to manage it immediately [12]. In other words, the level of staff in the ambulance participated in the transfer should have protocol to be followed to ensure patients' transfer safety [16].…”

“…To date, no established protocol has been developed to guide such critical inter-facility transfers in Taiwan. Given that the transferring staff may encounter numerous uncertainties during the transfer process, such as alterations in consciousness, dyspnea due to aortic valve regurgitation resulting from the progression of type A AD, cardiac tamponade, elevated blood pressure induced by pain, or inadequate hemodynamic management before and during the transfer, the risk of cardiac arrest occurring during the process is even more severe [12,13]. Consequently, it is imperative to investigate and analyze the quality of current inter-facility transfers, considering variations in hemodynamic status before and after the transfer and the composition of the ambulance staff [14,15] responsible for the patient's care throughout the transfer process.…”

“…While a limited number of studies [12,16] have explored the safety of inter-facility transfers for patients with type A AD, it is crucial to prioritize these transfers to enhance the quality of care and the chances of survival. Therefore, this study aims to assess the quality of care provided to patients with type A AD who undergo inter-facility transfers at a single medical center in Taiwan.…”