From the Western Vascular Society
Variability in transfer criteria for patients with ruptured abdominal aortic aneurysm in the western United States Matthew W. Mell, MD, MS,a Peter A. Schneider, MD,b and Benjamin W. Starnes, MD,c Stanford, Calif; Honolulu, Hawaii; and Seattle, Wash Background: No standards exist for interhospital transfer of patients with ruptured abdominal aortic aneurysm (rAAA). As such, many facilities have developed individual approaches to transfer of these patients. The purpose of this study was to investigate areas of agreement and discord for transfer and to determine if current practices may serve as a starting point for developing universal transfer guidelines. Methods: A survey was prepared regarding requirements for transfer, factors regarding transport, and available resources at the accepting hospital. The survey was then offered to members of the Western Vascular Society. Responses were analyzed by physician practice type. Consensus was defined as at least 70% agreement for a response. Results: Response rate was 40%. The cohort comprised 51% from academic institutions and 94% from metropolitan areas. Patients with rAAA were accepted in transfer by 88% of respondents; a majority accepted transfers from distances of up to 100 miles or more. Most had no formal protocol for transfer or treatment of patients with rAAA. Wide variation was observed regarding local evaluation, clinical status at presentation, pre-existing medical comorbidity and required tests for determining suitability for transfer, and management during transport. Academic physicians were more likely to accept clinically unstable patients and to have capability to offer endovascular aneurysm repair. Conclusions: Wide variation was observed regarding clinical suitability for transfer, diagnostic criteria and tests before transfer, and essential resources required at the receiving hospital. Reducing existing variation and inefficiencies in the transfer process by developing standard guidelines may improve population-based outcomes for rAAA. (J Vasc Surg 2015;-:1-5.)
Ruptured abdominal aortic aneurysm (rAAA) remains common in contemporary practice, but not all medical facilities have sufficient resources to provide emergent definitive care for patients presenting with rAAA. These facilities therefore must consider transferring such patients to a secondary facility to provide a meaningful chance of survival. The western United States has unique barriers in considering a regional treatment strategy for rAAA. It encompasses a large geographic area, with limited resources for specialized vascular care. Many patients travel long distances to local care facilities and then need to be transferred additional distances for open surgery or endovascular aneurysm repair (EVAR). These long travel distances are reflected by an increased emergency
From the Division of Vascular Surgery, Stanford University, Stanforda; the Division of Vascular Therapy, Hawaii Permanente Medical Group and Kaiser Foundation Hospital, Honolulub; and the Division of Vascular Surgery, University of Washington, Seattle.c Author conflict of interest: none. Presented at the Twenty-ninth Annual Meeting of the Western Vascular Society, Loews Coronado Bay, Coronado, Calif, September 20-23, 2014. Reprint requests: Matthew W. Mell, MD, MS, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Ste H3600, Stanford, CA 94305-5642 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.03.032
department death rate for those presenting with rAAA in the West compared with that of other regions.1 With these challenges, individual facilities in the region may have developed different approaches to care of rAAA as no U.S. standard exists. We sought to investigate areas of accord and disagreement concerning the interhospital transfer of patients with rAAA, with an additional goal of using our findings as a starting point for development of regional transfer guidelines for best practice.2 METHODS We prepared a survey based on established evidencebased care, including variables from a survey of experts conducted in the United Kingdom.2 Data included physician demographics, practice setting and type, presence of local transfer guidelines or rAAA treatment protocols, and resources available or needed. We also included questions regarding requirements for transfer (patient age, clinical status, and premorbid health), imaging, specific factors surrounding management of the transport, and available resources at the accepting hospital. Survey responses were anonymous, although disclosure of name and institutional affiliation of the respondent was optional. Institutional Review Board approval and consent were not required as patients were not directly involved in the survey and no personal health information was collected. We then invited all members of the Western Vascular Society (WVS) to participate in the survey through a web-based survey engine.3 The WVS is a regional society of board-certified vascular surgeons from Alaska, Arizona, 1
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2 Mell et al
California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oklahoma, Oregon, Utah, Washington, Wyoming, Alberta (British Columbia), and the Pacific Rim. This region includes 25% of the U.S. population and 51% of the landmass. The WVS has >200 active members and comprises vascular surgeons from academic, federal, community, health maintenance organization, and safety-net practices. Surgeons must have practiced in the region for at least 2 years to be eligible for membership. Statistical analysis. We tabulated and analyzed all responses of academic physicians with those of physicians from other practice types. Consensus was defined as at least 70% agreement for a response based on established methods.2 We compared categorical responses with either c2 or Fisher exact test. Statistical analysis was performed with Stata version 11.2 (StataCorp LP, College Station, Tex). RESULTS A total of 85 surveys were available for analysis, representing a response rate of 40%. Data were 98% complete among the responders. Of the cohort, 51% were from academic institutions, 94% practiced in a metropolitan or urban setting, and 61% provided care in a hospital with some trauma designation (41% level 1, 12% level 2, 8% level 3). Most (89%) respondents accepted transfers. Patients with rAAA were accepted in transfer by 90% of urban physicians and 60% of those practicing in smaller communities. More than half of these (and all from nonmetropolitan areas) accepted transfers from distances of 100 miles or more. Of the responses, 49% were anonymous. A majority (60%) of physicians who accepted rAAA transfers did not have a formal protocol for treatment of rAAA, and >70% did not use a transfer protocol or clinical guidelines for transfer. Nearly all (91%) offered EVAR for rAAA (rEVAR), whereas 79% offered rEVAR with local anesthesia, 79% had on-site inventory for EVAR, and 79% reported the ability to remotely view radiographic images. A discussion between the local physician and accepting vascular surgeon was conducted before transfer with 59% of respondents. Evaluation by a local surgeon was required by 15%, whereas 20% accepted transfers with no discussion and 6% accepted a local evaluation by a resident physician. Age was not a deterrent to transfer as 88% of respondents reported no age exclusions (Table I). Consensus was present regarding some measures of clinical status at presentation; 74% would withhold transfer after cardiac arrest requiring cardiopulmonary resuscitation, and 73% would offer transfer for patients requiring inotropes. Pre-existing medical comorbidity was not a criterion for transfer in 69% of those surveyed. Lack of consensus was noted regarding the intubated patient as well as the patient’s baseline performance status as 64% would offer transfer regardless of baseline ability to perform activities of daily living. Wide variation was observed regarding the necessity of required tests before transfer. Less than half (41%) had no
test requirements before transfer, whereas the remainder required some form of imaging (27% required ultrasound, 20% required ultrasound or computed tomography [CT], and 12% required CT). A minority required other tests: 15% required electrocardiography, 8% required a laboratory blood test to rule out pancreatitis, and 4% required crossmatched blood. For the transport, 81% favored fluid resuscitation to maintain a systolic blood pressure of at least 70 mm Hg, whereas the remaining 19% favored a systolic blood pressure goal of 90 mm Hg. Only one third favored transport with O-negative blood. Significant differences were observed in transfer criteria for rAAA between academic and nonacademic physicians (Table II). Physicians practicing in academic centers were more likely to accept patients for transfer requiring inotropes for blood pressure support, accepted lower blood pressure during transport, and were more likely to accept transport without required tests. Physicians practicing at academic centers had greater ability to remotely view images before arrival and greater ability to offer EVAR for rAAA under general or local anesthesia with on-site stent graft inventory. DISCUSSION No standards exist in the United States for transfer of a patient with rAAA, and our study shows that current practices can vary widely. A paucity of evidence in the literature has likely contributed to the range of opinion about essential clinical characteristics and criteria, patient management, and transfer conditions in considering transfer for patients with rAAA. The results from our survey support this diversity in opinion as consensus was absent regarding level of evaluation before transfer, diagnostic criteria and tests before transfer, and essential resources at the receiving hospital. Most respondents did not consider a patient’s underlying health or lifestyle relevant to the decision-making process, perhaps reflecting the absence of established criteria or the lack of reliable information at the point of care. A comparison of our survey results with those of a recent UK study2 revealed some similarities and other striking differences. Both groups reached consensus that age did not preclude transfer and that a systolic blood pressure of 70 mm Hg was an acceptable goal of fluid management during transfer. Opinions were similar regarding suitable patient conditions for transfer. Respondents from both groups reached consensus that patients with hypotension requiring inotropes were suitable for transfer, but patients suffering cardiac arrest requiring cardiopulmonary resuscitation were not suitable. Conversely, UK respondents were more willing to transfer patients evaluated by less specialized physicians and without a CT scan (38% vs 84%). It is possible that surgeons in the United Kingdom are more confident in an emergency department diagnosis of rAAA as it is a core competence of every UK emergency medicine trainee to detect rAAA using ultrasonography, even though CT is highly accurate for diagnosis of rAAA, with a reported 98.3% sensitivity, 92.3% specificity, 95.0%
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Table I. Consensus for interhospital transfer of patients with diagnosis of ruptured abdominal aortic aneurysm (rAAA)a Responses (%) Minimum level of evaluation for transfer No discussion, transfer to vascular service Resident to resident Resident to attending Must be assessed by local surgeon Attending to attending Diagnostic criteria necessary before accepting transfer Abdominal pain and hypotension Known AAA with symptoms/collapse In-hospital diagnosis without imaging Ultrasound in ED with symptoms/collapse CT scan, any CT scan, read by radiologist Maximum patient age, years, eligible for transfer
Variability in transfer criteria for patients with ruptured abdominal aortic aneurysm in the western United States Matthew W. Mell, MD, MS,a Peter A. Schneider, MD,b and Benjamin W. Starnes, MD,c Stanford, Calif; Honolulu, Hawaii; and Seattle, Wash Background: No standards exist for interhospital transfer of patients with ruptured abdominal aortic aneurysm (rAAA). As such, many facilities have developed individual approaches to transfer of these patients. The purpose of this study was to investigate areas of agreement and discord for transfer and to determine if current practices may serve as a starting point for developing universal transfer guidelines. Methods: A survey was prepared regarding requirements for transfer, factors regarding transport, and available resources at the accepting hospital. The survey was then offered to members of the Western Vascular Society. Responses were analyzed by physician practice type. Consensus was defined as at least 70% agreement for a response. Results: Response rate was 40%. The cohort comprised 51% from academic institutions and 94% from metropolitan areas. Patients with rAAA were accepted in transfer by 88% of respondents; a majority accepted transfers from distances of up to 100 miles or more. Most had no formal protocol for transfer or treatment of patients with rAAA. Wide variation was observed regarding local evaluation, clinical status at presentation, pre-existing medical comorbidity and required tests for determining suitability for transfer, and management during transport. Academic physicians were more likely to accept clinically unstable patients and to have capability to offer endovascular aneurysm repair. Conclusions: Wide variation was observed regarding clinical suitability for transfer, diagnostic criteria and tests before transfer, and essential resources required at the receiving hospital. Reducing existing variation and inefficiencies in the transfer process by developing standard guidelines may improve population-based outcomes for rAAA. (J Vasc Surg 2015;-:1-5.)
Ruptured abdominal aortic aneurysm (rAAA) remains common in contemporary practice, but not all medical facilities have sufficient resources to provide emergent definitive care for patients presenting with rAAA. These facilities therefore must consider transferring such patients to a secondary facility to provide a meaningful chance of survival. The western United States has unique barriers in considering a regional treatment strategy for rAAA. It encompasses a large geographic area, with limited resources for specialized vascular care. Many patients travel long distances to local care facilities and then need to be transferred additional distances for open surgery or endovascular aneurysm repair (EVAR). These long travel distances are reflected by an increased emergency
From the Division of Vascular Surgery, Stanford University, Stanforda; the Division of Vascular Therapy, Hawaii Permanente Medical Group and Kaiser Foundation Hospital, Honolulub; and the Division of Vascular Surgery, University of Washington, Seattle.c Author conflict of interest: none. Presented at the Twenty-ninth Annual Meeting of the Western Vascular Society, Loews Coronado Bay, Coronado, Calif, September 20-23, 2014. Reprint requests: Matthew W. Mell, MD, MS, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Ste H3600, Stanford, CA 94305-5642 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.03.032
department death rate for those presenting with rAAA in the West compared with that of other regions.1 With these challenges, individual facilities in the region may have developed different approaches to care of rAAA as no U.S. standard exists. We sought to investigate areas of accord and disagreement concerning the interhospital transfer of patients with rAAA, with an additional goal of using our findings as a starting point for development of regional transfer guidelines for best practice.2 METHODS We prepared a survey based on established evidencebased care, including variables from a survey of experts conducted in the United Kingdom.2 Data included physician demographics, practice setting and type, presence of local transfer guidelines or rAAA treatment protocols, and resources available or needed. We also included questions regarding requirements for transfer (patient age, clinical status, and premorbid health), imaging, specific factors surrounding management of the transport, and available resources at the accepting hospital. Survey responses were anonymous, although disclosure of name and institutional affiliation of the respondent was optional. Institutional Review Board approval and consent were not required as patients were not directly involved in the survey and no personal health information was collected. We then invited all members of the Western Vascular Society (WVS) to participate in the survey through a web-based survey engine.3 The WVS is a regional society of board-certified vascular surgeons from Alaska, Arizona, 1
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2 Mell et al
California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oklahoma, Oregon, Utah, Washington, Wyoming, Alberta (British Columbia), and the Pacific Rim. This region includes 25% of the U.S. population and 51% of the landmass. The WVS has >200 active members and comprises vascular surgeons from academic, federal, community, health maintenance organization, and safety-net practices. Surgeons must have practiced in the region for at least 2 years to be eligible for membership. Statistical analysis. We tabulated and analyzed all responses of academic physicians with those of physicians from other practice types. Consensus was defined as at least 70% agreement for a response based on established methods.2 We compared categorical responses with either c2 or Fisher exact test. Statistical analysis was performed with Stata version 11.2 (StataCorp LP, College Station, Tex). RESULTS A total of 85 surveys were available for analysis, representing a response rate of 40%. Data were 98% complete among the responders. Of the cohort, 51% were from academic institutions, 94% practiced in a metropolitan or urban setting, and 61% provided care in a hospital with some trauma designation (41% level 1, 12% level 2, 8% level 3). Most (89%) respondents accepted transfers. Patients with rAAA were accepted in transfer by 90% of urban physicians and 60% of those practicing in smaller communities. More than half of these (and all from nonmetropolitan areas) accepted transfers from distances of 100 miles or more. Of the responses, 49% were anonymous. A majority (60%) of physicians who accepted rAAA transfers did not have a formal protocol for treatment of rAAA, and >70% did not use a transfer protocol or clinical guidelines for transfer. Nearly all (91%) offered EVAR for rAAA (rEVAR), whereas 79% offered rEVAR with local anesthesia, 79% had on-site inventory for EVAR, and 79% reported the ability to remotely view radiographic images. A discussion between the local physician and accepting vascular surgeon was conducted before transfer with 59% of respondents. Evaluation by a local surgeon was required by 15%, whereas 20% accepted transfers with no discussion and 6% accepted a local evaluation by a resident physician. Age was not a deterrent to transfer as 88% of respondents reported no age exclusions (Table I). Consensus was present regarding some measures of clinical status at presentation; 74% would withhold transfer after cardiac arrest requiring cardiopulmonary resuscitation, and 73% would offer transfer for patients requiring inotropes. Pre-existing medical comorbidity was not a criterion for transfer in 69% of those surveyed. Lack of consensus was noted regarding the intubated patient as well as the patient’s baseline performance status as 64% would offer transfer regardless of baseline ability to perform activities of daily living. Wide variation was observed regarding the necessity of required tests before transfer. Less than half (41%) had no
test requirements before transfer, whereas the remainder required some form of imaging (27% required ultrasound, 20% required ultrasound or computed tomography [CT], and 12% required CT). A minority required other tests: 15% required electrocardiography, 8% required a laboratory blood test to rule out pancreatitis, and 4% required crossmatched blood. For the transport, 81% favored fluid resuscitation to maintain a systolic blood pressure of at least 70 mm Hg, whereas the remaining 19% favored a systolic blood pressure goal of 90 mm Hg. Only one third favored transport with O-negative blood. Significant differences were observed in transfer criteria for rAAA between academic and nonacademic physicians (Table II). Physicians practicing in academic centers were more likely to accept patients for transfer requiring inotropes for blood pressure support, accepted lower blood pressure during transport, and were more likely to accept transport without required tests. Physicians practicing at academic centers had greater ability to remotely view images before arrival and greater ability to offer EVAR for rAAA under general or local anesthesia with on-site stent graft inventory. DISCUSSION No standards exist in the United States for transfer of a patient with rAAA, and our study shows that current practices can vary widely. A paucity of evidence in the literature has likely contributed to the range of opinion about essential clinical characteristics and criteria, patient management, and transfer conditions in considering transfer for patients with rAAA. The results from our survey support this diversity in opinion as consensus was absent regarding level of evaluation before transfer, diagnostic criteria and tests before transfer, and essential resources at the receiving hospital. Most respondents did not consider a patient’s underlying health or lifestyle relevant to the decision-making process, perhaps reflecting the absence of established criteria or the lack of reliable information at the point of care. A comparison of our survey results with those of a recent UK study2 revealed some similarities and other striking differences. Both groups reached consensus that age did not preclude transfer and that a systolic blood pressure of 70 mm Hg was an acceptable goal of fluid management during transfer. Opinions were similar regarding suitable patient conditions for transfer. Respondents from both groups reached consensus that patients with hypotension requiring inotropes were suitable for transfer, but patients suffering cardiac arrest requiring cardiopulmonary resuscitation were not suitable. Conversely, UK respondents were more willing to transfer patients evaluated by less specialized physicians and without a CT scan (38% vs 84%). It is possible that surgeons in the United Kingdom are more confident in an emergency department diagnosis of rAAA as it is a core competence of every UK emergency medicine trainee to detect rAAA using ultrasonography, even though CT is highly accurate for diagnosis of rAAA, with a reported 98.3% sensitivity, 92.3% specificity, 95.0%
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Table I. Consensus for interhospital transfer of patients with diagnosis of ruptured abdominal aortic aneurysm (rAAA)a Responses (%) Minimum level of evaluation for transfer No discussion, transfer to vascular service Resident to resident Resident to attending Must be assessed by local surgeon Attending to attending Diagnostic criteria necessary before accepting transfer Abdominal pain and hypotension Known AAA with symptoms/collapse In-hospital diagnosis without imaging Ultrasound in ED with symptoms/collapse CT scan, any CT scan, read by radiologist Maximum patient age, years, eligible for transfer
