Successful system-wide protocols to address the care of STEMI patients have spurred facilities like Clarian Cardiovascular at Methodist Hospital in Indianapolis to develop similar programs of facilitated care to treat other time-sensitive vascular emergencies such as aortic aneurysms and dissections. As a result, Clarian has reduced its time to treatment and mortality rates, while expanding its referral base.
Clarian launched the level 1 vascular emergency program in August 2009 with a goal of improving clinical outcomes for patients with acute thoracic aortic aneurysms, dissections, abdominal aortic aneurysms (AAAs) and acute limb ischemia.
Traditionally, these high-risk, emergent cases arrive at a hospital emergency department (ED), get evaluated by the ED staff, who then contact the surgeon who may have to be called in—all the while delaying diagnosis time. The surgeon and fellows would then consult the patient about treatment choices, and if an operation was required, the operating room (OR) staff would then be rounded up.
“This process typically consumes more than two hours, even with a proficient staff,” explains Michelle Hare, director of invasive cardiovascular services for Clarian.
However, the necessity of reducing time to treatment for these patients is integral to successful outcomes. For instance, from the time an aortic dissection occurs, the mortality rate increases approximately 1 to 2 percent per hour. “Since dissections typically occur outside of a hospital, it is critical to quickly transport, diagnose and treat the patient in the OR in a timely manner,” says John W. Fehrenbacher, MD, a cardiothoracic surgeon with Clarian Cardiovascular Surgeons.
Clarian learned from its STEMI network that all staff and referring providers had to be working from the same treatment decision algorithm, which involves standardizing every step of the process. “The previous model was riddled with variables,” says Hare.
Employing a model from its STEMI network, Clarian began accepting these emergent patients from other facilities through its already-established transfer program using ambulances or a helicopter. The foundation of the transfer program is the one-call streamlined process. When an outside ED physician diagnoses a vascular emergency, a call prompts a number of actions, including:
- Facilitation of transportation for the patient, either by air or ground, to Methodist, provided by Clarian’s LifeLine telecom personnel;
- Activation of the appropriate surgeon(s) and treatment team, including the OR charge nurse and the accepting surgeon, who call the referring ED back, when it is determined whether the patient needs to be transferred for additional medical or surgical/endovascular treatment;
- Facilitation of physician-to-physician communication and nursing report; and
- Guaranteed bed placement for the patient.
“With these life-threatening emergencies, the patients are never diverted with the new system, because the bed control gets notified at the same time the doctor gets notified that the patient is being transferred,” says Hare. “The referring hospitals are relieved when they learn that it only requires one phone call and our ultimate goal is get the patient to Clarian within 30 minutes, which has resulted in a lot of repeat business from those facilities that have availed themselves of the service once.”
In the year since the program’s initiation, Clarian has seen an approximate 33 percent volume increase in these patient populations.
Also, during the transfer process, Clarian physicians can access the patient’s images via a password-encrypted web portal, which can transfer DICOM images for assessment purposes from non-Clarian facilities. Those images also can be stored in Clarian’s PACS for later downloads, if necessary. Thirteen Clarian affiliates throughout Indiana all share a similar PACS, but this image-viewing process is for non-Clarian facilities. “This process will reduce radiation exposure through unnecessary repeat exams, as well as reduce the amount of time it takes to get a patient into the OR,” Hare says.
Fehrenbacher notes that the electronic image access can allow a surgeon to securely access images from a home computer. While these large CT image sets still take about 15 to 20 minutes to download, the new process is “much faster.” Previously, patient images were physically