Acute Aortic Treatment Center – A New Paradigm for Aortic Emergencies

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					                             International Forum on Quality and Safety in Health Care 2010

  Acute Aortic Treatment Center – A New Paradigm for Aortic Emergencies
        Faisal Masud, M.D., Mark Davies, M.D., Ph.D., M.B.A. and Daynene Vykoukal, Ph.D.

    Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, Texas USA

1) Context: This Acute Aortic Treatment Center (AATC) program is an interdisciplinary, collaborative
effort between the departments of Cardiovascular Surgery and Cardiovascular Critical Care at the
Methodist DeBakey Heart & Vascular Center. Staff involved in this initiative included a coordinated team
of ER physicians, cardiovascular ICU physicians, cross sectional imaging radiologists and technicians,
CV surgeons, CV anaesthesiologists, in house on call nursing staff. This treatment pathway specifically
focused on patients presenting to the ER with potentially lethal acute aortic syndromes.
2) Problem: Acute aortic syndromes are life-threatening ailments, and rapid treatment is critical as
mortality rates rise with increasing time after the acute episode. Such clinical entities include Type A and
B aortic dissections, intramural hematoma, ruptured or symptomatic thoracic and abdominal aortic
aneurysms, and thoracic aortic injury.
3) Assessment of problem and analysis of its causes: Mortality of acute aortic syndrome is 1% per
hour and thus time to treatment is crucial. Therefore methods of diagnosis and modes of treatment need
to be both efficient and effective. Keys to successful treatment include early diagnosis, transfer to the
appropriate care facility, rapid intervention (medical therapy, endovascular or surgical treatments),
availability of high quality cardiovascular anaesthesia, critical care and surgery. The overall solution to
this problem must include an organizational structure of physician involvement, improved patient flow
within the treating hospital, an educational plan to raise awareness among the general public,
emergency medical technicians (EMTs), and referring hospitals.
4) Strategy for change: The MDHVC developed and instituted an AATC pathway designed to facilitate
accurate diagnosis and immediate intervention (medical management or optimization prior to surgical
management) with a goal of “door to intervention time under 90 minutes” in order to reduce mortality and
morbidity from acute aortic diseases. The pathway was modelled after those designed for acute stroke
and myocardial infarction and dictates the appropriate schedule of events to be followed in the case of
an acute aortic syndrome, including lab work, imaging for diagnosis, channels for communication
between specialists, and physical routing of the patient through the hospital.
5) Measurement of improvement: A database of patients admitted with aortic disease one year before
(2007) and after initiation of pathway (2008) was developed. Society of Vascular Surgery criteria were
used to score co morbidities, to determine and categorize anatomic and functional outcomes.
Multivariate analysis was performed for categorical outcomes and Cox proportional analysis for time-
dependent outcomes.
6) Effects of changes: 621 patients reported with aortic disease to the cardiovascular services; 306
patients were considered to have acute disease. Compared to the year before the AATC was instituted,
there was a 10% increase in the total number of admissions and a 25% increase in acute pathology after
setting up the AATC (p=0.02). There was a 2 fold increase in thoracic aortic dissections admitted to the
service. Initiation of the treatment pathway resulted in a highly significant reduction in time to definitive
therapy (64% decrease) (p=0.0001). Co morbidity scores were equivalent between the two cohorts.
Despite the increase in acuity, mortality (4% vs. 6%) and morbidity (41% vs. 45%) rates were unchanged
and there were trends to a lower ICU (5 vs. 4 days) and total hospital (11 vs. 10 days) stays.
7) Lessons learnt: Focus on acute aortic disease has raised community awareness. It is essential to
enhance and maintain community and hospital awareness of acute aortic syndromes. The AATC is
currently refining protocols to reduce door to intervention time and identifying elements that contribute to
potential delays in the treatment process.
8) Message for others: AATC pathways save lives. Widespread adoption of the acute aortic treatment
pathway (AATC) is recommended.