Methodist Hospital in Indianapolis has standardized the steps to treat aortic emergencies.

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.

Why standardize?

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 transferred on CD or DVDs, and the images often were not interoperable with Clarian’s PACS.

The decision-making process was an “intensive, large-scope exercise because of the multidisciplinary teams required to treat these patient populations,” Hare says. “We created a Management Standards Document, which included how we want the referring ED to take care of these patients, as well as our own ED and OR staff. The final decisions got compiled in this document, which had to be approved by a series of committees to ensure the physicians and support staff are following the same guidelines.”

Abdominal aortic aneurysms

Approximately two out of three patients with a ruptured AAA die before they ever reach a hospital (Br J Surg 1988;75(8):733-736). For those patients who actually make it to the hospital and have surgery, there is a 50 to 70 percent mortality rate associated with a ruptured AAA. Despite the need for emergent treatment, there is no standardized, guideline-recommended timeline from ruptured AAA diagnosis to treatment.

“The only reason these patients don’t die  immediately is because the retroperitoneum, which separates the major blood vessels from the bowels, is thick and tough enough to hold a small leak in place for a while. However, if the patient’s blood pressure rises and causes rupture or pumping of blood into the free abdominal cavity, the patient will likely bleed to death before we can rush him/her to surgery,” explains Michael Dalsing, MD, a vascular surgeon with Indiana University Vascular Surgery.

Once patients are diagnosed in the hospital setting, the goal is to keep a patient’s blood pressure low to avoid a free rupture, and transport them quickly to the operating room, says Dalsing. He adds that an aortic endograft procedure lends itself well to emergent cases, as long as the patient is a suitable candidate, because it takes far less time than open surgery.  

Due to the program, Clarian discovered the possibility of treating about 40 percent of ruptured AAAs with the endograft procedure. “An emergency endograft can be conducted more rapidly, because the abdomen doesn’t have to be opened,” Dalsing says. “Also, if you can convert treatment to an endograft procedure, the mortality rate decreases 15 to 20 percent.” While he can’t speak to a specific decrease in mortality rates with standard open operation because of the historical controls, Dalsing suggests the mortality has been reduced due to the new program.  

Over the course of the program’s first six months, Clarian has noted that the decision-to-treatment time marker decreased by 50 percent. “We are continuing to work through the process to narrow this time marker,” notes Dalsing.

Aortic dissection

While there is a growing trend in the U.S. to treat ruptured AAAs in a facilitated manner, far fewer facilities are treating aortic dissections in the same manner, says Hare.   

The in-hospital mortality rate for patients diagnosed with thoracic aortic dissection is 26 percent (Circ Cardiovasc Qual Outcomes 2010;3:424–430). In this recent study, Harris et al found that implementing quality improvement protocols and a multidisciplinary approach to treat dissection can result in a 43 percent reduction in mortality and improve delays in care by almost two hours.

Clarian’s mortality rate for acute type A aortic dissection is approximately 10 percent, says Fehrenbacher, adding that he hopes that number improves further with the expedited protocols.

Currently, there are no national guideline-recommended presentation-to-treatment times for aortic dissection—as in the less than 90 minutes for door-to-balloon times for acute MI. However, if the diagnosis is concretely made prior to arrival, the average goal is approximately 90 minutes from time of presentation at Clarian.

Facilities are willing to transfer these various vascular emergencies due to the complexity of the disease states. “There seems to be a need out there for these types of programs, so as people become aware, they will send patients to receive this care,” Dalsing says.