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Experience After Implementation of an Acute Cardiovascular Emergency Protocol (ACEP)

Journal of Vascular Surgery - DOI: http://dx.doi.org/10.1016/j.jvs.2017.06.053


Objectives: Prompt treatment of cardiovascular emergencies is associated with improved outcomes. We describe findings after implementation of an acute cardiovascular emergency protocol (ACEP) for diagnoses of aortic dissection (AD), ruptured aneurysm (RA), and acute limb ischemia (ALI).

Methods: In 2011, a multidisciplinary committee created our center’s ACEP with goals of expediting treatment, improving outcomes, and increasing referrals. The referral mechanism, management at the referring hospitals and in transit, and care on arrival were protocolized. Regional practice dictated that referring hospitals retain control of transportation. Internally, ACEP policies included the receiving surgeon and an anesthetist meeting the patient on arrival, immediate computed tomography if needed, and having an operating room ready before patient arrival, all automatic without need for further communication. ACEP goals and protocols were disseminated locally and regionally. Data were recorded prospectively.

Results: From April 2012 through December 2016, the ACEP was activated 346 times. Volume was stable over time (73 to 83 activations/year). The mean distance traveled was 50.8 miles (range, 3.5-170 miles). Of 171 ADs, 117 were type A; 82% had surgery. Mean time from arrival to the operating room decreased from 326 minutes in 2013 to 80 minutes in 2016. Mean time from referral call to arrival was 105 minutes. In-hospital mortality was 20%. Neither changed over time. Of 81 RAs, 3 were ascending aortic, 11 descending thoracic, 64 abdominal, and 3 thoracoabdominal. Surgery was offered to 63, 3 died upon arrival, 6 were palliated, and 9 were found to have no RA. Mean time from arrival to the operating room decreased from 142 minutes in 2013 to 104 minutes in 2016. Mean time from the referral call to arrival was 106 minutes. In-hospital mortality was 33%. Neither changed over time. Of 94 ALI cases, 28 were Rutherford class I, 19 class IIa, 36 class IIb, and 11 class III. Thirty-one class IIb patients had surgery, with a mean time from arrival to the operating room of 297 minutes. The mean time from the referral call to arrival was 143 minutes. Neither changed over time. Overall ALI patient survival was 93%, and the major amputation rate was 9.6%, of which over half were class III patients.

Conclusions: An ACEP streamlined care of patients with AD and RA after arrival to our institution but did not speed transfer, alter mortality, or increase volumes over time. Control of transportation mechanisms may be an opportunity to speed transfer time.



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