CV
preoperative unconsciousness, and low temperature at the
end of aortic repair are all major predictors of mortality.
Transfemoral insertion of an aortic occlusion balloon into
the suprarenal aorta before anesthesia induction reduces the risk of circulatory collapse through inflation of the
aortic occlusion balloon should the blood pressure drop
during intubation. Expedient and pre-intubation control of
the bleed may further reduce postoperative complications
to include intra- abdominal hypertension (IAH), abdominal
compartment syndrome (ACS), and multiple organ failure
(MOF), with renal failure being the largest predictor of
postoperative mortality.
Who initiates the Code Rupture protocol?
The ED physician may initiate the Code Rupture protocol
for patients diagnosed in the Emergency Department, with
or without consult from a vascular surgeon. A phone call is
placed to our healthcare system’s communication hub, Physician’s Connection Line (PCL), who then delivers a team
page “Code Rupture ED room ___.” The Surgical team
immediately prepares for the patient to arrive at the OR.
For referring ED physicians from other hospitals, the protocol is initiated by their calling PCL, who places the referring
physician into a conference call with the on-call vascular
surgeon who will initiate the code as appropriate. Once the
decision has been made to activate the protocol, PCL delivers a team page, air or ground transport is immediately
arranged, and the Code Rupture team prepares for arrival.
Timing Goals
The time goals established are:
1.
2.
3.
4.
20 minutes from ED arrival to OR
20 minutes from diagnosis to OR
20 minutes from OR door to skin incision
90 minutes from skin incision to aneurysm exclusion
the Code Rupture education in the form of staff meetings,
huddles, poster board presentations, and books. For the
Cath lab team, a Code Rupture book was designed that
outlined the entire protocol, as well as the cath team’s roles
and responsibilities.
Several copies of this book were printed and staged to give
the staff an opportunity to read and internalize. Once all
departments were educated, mock Code Rupture drills were
conducted to test the protocol.
Once the Code Rupture drills were announced, a renewed
surge in staff interest and education ensued, which brought
the entire team to a higher level of performance. A few challenges were uncovered during the drills, all of which were
addressed and resolved immediately.
MD-to-MD education was presented to the ED physicians
by the vascular surgeons and key staff to outline the Code
Rupture protocol, with emphasis on when and how to
initiate it. The education also included information on managing the rAAA patient with permissive hypotension for
better clinical outcomes, per evidence-based practice and
research, and covered differential diagnosis, preoperative
diagnostic imaging and labs.
Orientation, education and training of regional hospital
personnel were organized to ensure maximization of patient benefits.
CONTINUOUS PROCESS IMPROVEMENT
From idea to realization, the time frame to build and implement the Code Rupture protocol took nine months. Several
small changes implemented during the developmental
stages yielded significant results.
For example, the anesthesia process paradigm shift from
intubation first to inserting an occlusion balloon before
induction yielded a 3-4 fold decrease in OR door to incision
time. This change alone may account for fewer intra and
postoperative complications.
DOCUMENTATION
Resources were utilized from other similar CMC documented protocols, which saved a considerable amount of time
building the Code Rupture Protocol. Once “modules” of the
protocol were designed, the “modules” were then joined
together to form a seamless Code Rupture algorithm. A
Code Rupture Guide, along with an algorithm flowchart was
finalized to outline the entire process, to include predetermined decisions, pathways, and timing goals of each phase.
“Several small changes implemented during the developmental
stages yielded significant results.
CODE RUPTURE
EDUCATION
The development of the Code Rupture process took approximately 3 months, which then led to the educational phase.
This phase began with identifying the multidisciplinary
educational points of contact (POC) for each stakeholder
involved in the care of the rAAA patient, and deciding what
level of education needed to be achieved.
The Code Rupture Guide and flowchart were forwarded
to each Code Rupture education POC, who then extended
CV DIRECTIONS VOL. 2, NO. 2
CONCLUSION
The opportunity to benefit rAAA patients remains significant. The multidepartmental, multidisciplinary development and implementation of the CMC Code Rupture Protocol has improved the regional rAAA process. Intuitively,
in-house and regional efficiency and patient care have been
enhanced. The program is being monitored closely. Data is
currently being obtained to quantify the changes.
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