Multidisciplinary Standardized Care for Acute Aortic Dissection

Abstract

"No physician can diagnose a condition he never thinks about."-Michael DeBakey P atients with acute aortic dissection (AAD) have an in-hospital mortality of 26%, and for those patients with type A AAD, the mortality risk is 1% to 2% per hour until emergency surgical repair is performed. 1,2 It is therefore critical that AAD be recognized promptly and that surgical care be provided expeditiously. Data from the International Registry of Acute Aortic Dissection (IRAD) indicate that the median time from emergency department (ED) presentation to definitive diagnosis of AAD is 4.3 hours, with an additional 4 hours between diagnosis and surgical intervention for type A patients. 2,3 A portion of the delay to surgery is often the result of the patient's presenting to smaller community hospitals underequipped to manage emergent AAD. Transfer to high-volume aortic care centers with highly specialized facilities and expertise is routine, but even at such centers, current surgical mortality is 25%. 4 Goals and Vision of the ProgramIn an effort to address factors that delay AAD recognition and optimal management, a standardized, quality-improvement protocol for the regional treatment of AAD was developed and implemented with the goal of providing consistent, integrated, and coordinated care for patients with AAD throughout all phases of care. Modeled, in part, after a successful regional program for ST-segment elevation myocardial infarction, 5 , the specific aims of the program were to decrease the time from hospital arrival to diagnosis and treatment and to improve clinical outcomes for patients with AAD. A collaborative team designed program elements directed at (1) increasing awareness and knowledge of AAD among emergency care providers, (2) standardizing optimal care for AAD through the use of a formal protocol, (3) improving care coordination and communication across disciplines, and (4) providing feedback and quality improvement to treating clinicians. This report highlights key components of the protocol, the process of implementation, and initial clinical outcomes. Methods Local Challenges in ImplementationAn interdisciplinary committee (cardiologists, cardiovascular [CV] surgeons, vascular medicine and surgeons, cardiac anesthesiologists, radiologists, AAD program nurses, community and tertiary hospital ED physicians, and a CV administrator) worked to define an ideal AAD care pathway extending from rural hospital diagnosis to tertiary care hospital discharge, and the following areas were targeted for process improvement: (1) delayed initial diagnosis, (2) nonstandardized diagnostic testing and pharmacotherapy, (3) delays occurring between community hospital presentation and interhospital transfer, (4) delays between AAD center arrival and the initiation of surgical care, (5) delays in availability and preparation of blood products for transfusion, (6) inconsistent provision of intraoperative aortic imaging; and (7) inconsistent follow-up after discharge.

The utility of the aortic dissection team: outcomes and insights after a decade of experience

“…However, our study and others show that regionalization of ATAAD care is possible (9,10), and could likely be expanded through national cooperative efforts, as exemplified by the American Heart Association Lifeline Mission for the rapid diagnosis and transfer of STEMI patients to PCI-capable hospitals (7,8). A similar initiative aimed at concentrating ATAAD patients at one or two designated hospitals in large population centers, as well as improved transport of ATAAD patients to tertiary institutions in rural areas, would produce new high-volume regional aortic receiving centers and presumably improve outcomes (9).…”

“…Although regional networks for the rapid triage and transfer of ST-segment elevation myocardial infarction (STEMI) (7,8) and trauma patients to specialized centers are well established, ATAAD patients are less amenable to centralization than other emergent/unstable patients due to the inability to diagnose ATAAD in the prehospital setting and the exceedingly small number of high-volume aortic dissection centers in the United States (4)(5)(6). Nonetheless, centralization of acute aortic dissection (AAD) care is an emerging focus of national quality improvement in cardiovascular medicine and likely offers the single best opportunity to improve outcomes from this challenging disease (9)(10)(11)(12)(13)(14)(15)(16), aside from prevention (17)(18)(19).…”

Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest

“…Building on the Level 1 experience, MHI has introduced protocols for other cardiac emergencies, including acute aortic dissection. 20 An interdisciplinary team at MHI-ANW developed a standardized protocol for cardiac arrest that includes timely initiation of TH and implemented the program as a further adjunct to the Level 1 system in 2006. Comprehensive education and protocol training were conducted at each participating hospital and at the helicopter and ground bases of 45 independent EMS providers.…”

Analysis of mortality in patients with early diagnosis of acute aortic dissection

“…Potreban je multidisciplinarni pristup s ciljem postavljanja pravovremene dijagnoze koji podrazumeva saradnju kardiologa, anesteziologa, vaskularnog hirurga i radiologa kao i adekvatna saradnja sa referentnim ustanovama u kojima se obavlja kardiohirurška intervencija (21). Treba razmišljati u pravcu implementacije protokola za zbrinjavanje pacijenata sa akutnom disekcijom aorte koji podrazumeva farmakoterapiju, dijagnostičke smernice čak i kontakt telefone sa referentnim ustanovama u kojima se obavlja kardiohirurška intevencija.…”