Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease

Abstract

PurposeAcute aortic diseases, such as aortic dissection and aortic aneurysm, can be life-threatening vascular conditions. In this study, we compared outcomes before and after the implementation of a critical pathway (CP) for patients with acute aortic disease at the emergency department (ED).Materials and MethodsThis was a retrospective observational cohort study. The CP was composed of two phases: PRE-AORTA for early diagnosis and AORTA for prompt treatment. We compared patients who were diagnosed with acute aortic disease between pre-period (January 2010 to December 2011) and post-period (July 2012 to June 2014).ResultsNinety-four and 104 patients were diagnosed with acute aortic disease in the pre- and post-periods, respectively. After the implementation of the CP, 38.7% of acute aortic disease cases were diagnosed via PRE-AORTA. The door-to-CT time was reduced more in PRE-AORTA-activated patients [71.0 (61.0, 115.0) min vs. 113.0 (56.0, 170.5) min; p=0.026]. During the post-period, more patients received emergency intervention than during the pre-period (22.3% vs. 36.5%; p=0.029). Time until emergency intervention was reduced in patients, who visited the ED directly, from 378.0 (302.0, 489.0) min in the pre-period to 200.0 (170.0, 299.0) min in the post-period (p=0.001). The number of patients who died in the ED declined from 11 to 4 from the pre-period to the post-period. Hospital mortality decreased from 26.6% to 14.4% in the post-period (p=0.033).ConclusionAfter the implementation of a CP for patients with acute aortic disease, more patients received emergency intervention within a shorter time, resulting in improved hospital mortality.

Spontaneous rupture of the ascending aorta

“…Diagnostic delay in a few cases along with a small sample size increased the mean door‐to‐OR time in this series (8.7 ± 13.7 h). However, the median door‐to‐OR time of 2.58 h represents the ideal management timeline according to the ATAE protocol and is comparable to other studies (evaluating an acute aortic protocol) . The shorter median time duration from triage to echo and CT also reflects the effectiveness of the ATAE protocol integration for a rare and difficult diagnosis (Table ).…”

“…In this series, the mean aortic diameter at rupture was 4.60 ± 0.62 cm (median = 4.3 cm) ( comparable to other studies (evaluating an acute aortic protocol). 5,11,12 The shorter median time duration from triage to echo and CT also reflects the effectiveness of the ATAE protocol integration for a rare and difficult diagnosis ( Table 3).…”

“…Spontaneous ascending aortic rupture is associated with a mortality rate of 57% . Time is critical in these patients as any delay in surgery is a major contributor to morbidity and mortality …”

“…2 Time is critical in these patients as any delay in surgery is a major contributor to morbidity and mortality. 5 We describe a series of patients who presented to our hospital with non-traumatic, spontaneous ascending aortic rupture from 2012 to 2017. These cases highlight the importance of timely imaging and a high index of suspicion to quickly and accurately establish a diagnosis.…”

Reduced length of stay and 30-day readmission rate on an inpatient vascular surgery service

“…Key to the success of these tools is the support of APP and nurses to promote adherence and recognize when deviation occurs. More recently, an urban tertiary care hospital published a comparison of acute aortic disease patient outcomes before and after implementation of clinical pathways, noting improved outcomes, decreased mortality, and decreased time to intervention [17]. Our experience was that some diagnosis groups had more predictable recovery and patients were less likely to deviate from the clinical pathway; these included patients undergoing the following procedures: carotid artery stent/endarterectomy, lower extremity amputations, angiography, EVAR for non-ruptured AAA, or aorta-iliac-femoral bypass.…”