Transfer Metrics in Patients With Suspected Acute Aortic Syndrome

Abstract

Society of Cardiology have established benchmarks for patient transfer times (door-in-door-out time and door-toballoon time) that serve as clinical performance measures for ST-segment-elevation myocardial infarction (STEMI) networks. Campaigns, such as D2B Alliance and Mission Lifeline, were also launched in an effort to reduce system delays in transfer and improve outcomes for subjects presenting with STEMI.1 This scrutiny on pre-and interhospital care has led to marked reductions in door-to-balloon times across the United States. 2Unlike STEMI, acute aortic syndrome (AAS) defined as acute aortic dissection, intramural hematoma, or penetrating aortic ulcer is a less frequent clinical event that lacks an effective diagnostic biomarker and requires definitive imaging for confirmation. The time-sensitive nature of AAS, complexity of surgery, and endovascular intervention and the relative paucity of institutions that deliver 24/7 state-of-the-art care strongly advocates for regional systems of care across the United States. Successful transfer of patients with AAS has previously been described through such efficient regional care models.3,4 Our aim was to evaluate safety and timeliness of transfer provided by our regional aortic network. The transfer metrics served by this analysis will help us improve as a network and more importantly serve as a benchmark to be replicated and improved on by others. Methods and ResultsOur AAS network shares a common hotline with our STEMI and stroke networks. On activation, a transfer team is dispatched immediately to the referring center. The transfer system is operated by critical care trained nurse practitioners and paramedics, who are equipped in handling all cardiovascular emergencies under direct consultation with cardiac intensive care unit (CCU) physicians. The transfer team's goal is to expedite safe transfer and optimize medical care during transfer for these patients. Transfer times were abstracted on consecutive patients transported with suspected AAS between March 2010 and May 2013. We defined total transfer time (TTT) as time from activation of AAS network to patient arrival at aortic center CCU and handover time (HT) as time from arrival of our transfer team at referring hospital to dispatch toward the tertiary center.A total of 359 patients were transferred from 84 different regional medical centers in the given time frame. Mean age was 65 years and 58% were men. Transfers were accomplished by the institutional critical care transfer system using ground ambulance (n=83), helicopter (n=248), or fixed-wing jet (n=28) from referring centers directly to our CCU bypassing the emergency department. Comprehensive TTT and HT data were available for 307 patients. Median transfer distance was 66 km (interquartile range, 23-117), and median TTT was 88 minutes (interquartile range, 67-117). More than 3 quarters (76%; n=234/307) of the patients were successfully transferred to the CCU within 2 hours of network activation ( Figure 1A). Median HT was 35 minutes (interquartile rang...

Determining the factors for interhospital transfer in advanced heart failure cases

“…In the cardiovascular field, studies have been conducted on the transfer of hospitals for AMI and acute aortic dissection (DA) and indicated the importance of early accurate diagnosis and transfer to a facility that can handle treatment as soon as possible [7] , [8] . The pathology in our study differs from AMI and DA in two aspects: First, unlike acute diseases such as AMI and DA, advanced HF has a time axis that follows an acute exacerbation in a relatively chronic course.…”

Management of patients with acute aortic syndrome through a regional rapid transport system

“…8 Finally, after the development of a centralized regional system for patients with AAS, the Cleveland Clinic noted drops in the overall mortality and surgical mortality from 19% and 10% to 10% and 4%, respectively. 9 These experiences provided mixed results but were published as endovascular techniques were evolving to become the mainstay for management of ruptured abdominal aortic aneurysms with an associated decrease in mortality. Furthermore, endovascular innovation during the same time frame dramatically changed the management of patients with type B dissections.…”

Surgical techniques in type A dissection

“…Due to techniques described above and improvements in perioperative care, the acute mortality for 889 patients presenting (from 2000-2014) with acute aortic syndrome of the ascending aorta at our institution was 5-10% (16). The in-hospital mortality of 114 patients managed surgically recently (March 2010 to May 2013) at our center was only 4% (17).…”