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Objectives:
While standardized protocols have been shown to improve safety in aviation and multidisciplinary care improves outcomes in oncologic surgery, a standardized multidisciplinary pathway for the treatment of rAAA has not yet been described. We aim to describe and evaluate a standardized clinical pathway for the care of rAAA.
Methods:
Since 2002 our institution has managed an average of 30 rAAA per year. In 2007 we developed and initiated a multidisciplinary clinical pathway to aid in expediting care of patients with rAAA from initial presentation at the referring facility to definitive care. This pathway includes electronic publication of prehospital care protocols for referring providers as well as streamlined system for electronic transfer of outside imaging and records. We have initiated protocols for prehospital and transfer providers including guidelines for permissive hypotension as well as emergent patient registration, emergency department bypass and transfer directly to the operating room once the patient arrives at our institution. Circulating and scrub nurse protocols for education and OR preparation are in place, as well as anesthetic guidelines including delay of induction until proximal aortic control is achieved. Finally, the rEVAR procedure and post-operative transfer of care is outlined in detail to achieve optimal patient outcomes.
Results:
Before initiation of the multidisciplinary pathway, 131 patients with rAAA presented between 2002 and 2007. 128 of these patients were treated with open surgical repair (OSR) with 30-day mortality rate of 57.8%. After initiation of our multidisciplinary clinical pathway, 118 patients presented with rAAA between July 2007 and February 2012. 100 were treated surgically, and 72 survived to discharge with an overall 30-day mortality of 28%. Subset analysis revealed 21 of 39 patients treated with OSR survived with 30-day mortality of 46% and 51 of 61 patients treated with EVAR survived with 30 day mortality of 16%.
Conclusions:
RAAA remains a clinical challenge despite advances in pre, intra and postoperative care. While adherence to protocols across multiple sites and specialties can be difficult, standardization of a multidisciplinary clinical pathway from prehospital transfer through postoperative ICU care is associated with improved patient outcomes following open and endovascular repair of rAAA suggesting there is benefit beyond the “EVAR first protocol” to a standardized multidisciplinary pathway.