Protocol Shrinks Ruptured Abdominal Aortic Aneurysm Treatment Time



CHICAGO – A dedicated protocol that streamlines the care pathway dramatically improved the timely care of patients with life-threatening ruptured abdominal aortic aneurysms, although overall outcomes held relatively steady.

Among 62 patients, the median overall door-to-treatment time decreased significantly from a preprotocol 183.5 minutes to 157 minutes post protocol (P = .05).

That included a significant drop in median emergency department-to-operating room time (35 minutes vs. 23 minutes; P = .035) and nonsignificant reductions in time spent at the referring hospital (150.5 minutes vs. 110 minutes) and in transit (52 minutes vs. 35 minutes), Dr. Raghu Motaganahalli reported on behalf of his colleagues at Indiana University, Indianapolis.

Data available on three-fourths of the patients suggest that the expedited care improved immediate outcomes. The percentage of patients who had a Glasgow Aneurysm Score greater than 100 and survived increased from 20% to 69% post-implementation, Dr. Motaganahalli said at the annual meeting of the Peripheral Vascular Surgery Society.

"Various therapeutic interventions, including endovascular therapy, have added to patient mortality," he said. "However, there’s still a need to have a dedicated protocol that enables early recognition by increasing awareness, effective communication, and rapid transfer to centers taking care of patients with ruptured aneurysms."

The Protocol at Indiana University Methodist Hospital

The level I vascular emergency program at Indiana University Methodist Hospital instituted a protocol for acute aortic emergencies, as well as limb-threatening ischemia, in August 2009. The transferring emergency department (ED) or attending physician initiates the process by calling a Lifeline Telecom toll-free number.

Lifeline Telecom arranges the transportation of the patient and calls the hospital operator, who sends out a burst page to the on-call vascular surgeon, OR charge nurse and vascular fellow, as well as the emergency medicine and trauma center (EMTC) charge nurse, cardiovascular critical care charge nurse, patient access team leader, level I vascular coordinator, main admission office, transfer center, chaplain, and security.

Meanwhile, the transferring ED faxes the patient’s face sheet to Lifeline, and the referring ED nurse calls in the patient report to the receiving ED charge nurse, Dr. Motaganahalli explained.

Upon receiving the page, the receiving surgeon and OR charge nurse call the same Lifeline number and hold a conference call with the transferring ED physician to determine whether the patient should go to the ED or directly to an OR. The surgeon then directs the OR charge nurse on the type of procedure to prepare, and the nurse sends a burst page to the OR team.

The surgeon is transferred by the operator to the EMTC physician, who reads the CT scans if they’re available. Indiana University Methodist Hospital is developing a central site where referring hospitals can upload images directly to its website, but for now, the hospital relies on transmission via CV Express or discs that arrive with the patient, Dr. Motaganahalli said.

The patients are mostly male, are transported by air, and have CT scans obtained at the referring facility. Of the 90 patients who have been treated since the protocol was adopted through November 2010, eight have died in transit or upon arrival.

Although all 26 preprotocol patients were treated with open repair, 36% of the 36 postprotocol patients have undergone endovascular repair, he said.

In all, 8 (30.7%) preprotocol patients died, compared with 11 (30.5%) postprotocol patients, including 3 who were treated endovascularly. Hospital length of stay and patient disposition were also similar.

Invited discussant Dr. Ravi Veeraswamy, a vascular surgeon from Emory University in Atlanta, asked whether there is a protocol in place for endovascular repair, and why shorter treatment times didn’t translate into a greater improvement in outcomes. Dr. Motaganahalli replied that the university is attracting more sick patients from across the state who previously would have died, and that these patients have worse hemodynamic values when they arrive.

He added that endovascular repair is based on purely anatomical criteria, and that they may use aortic balloon occlusion to temporarily obtain hemodynamic stability, but that these patients go on to open repair.

The authors reported no disclosures.

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