CV Directions Vol. 2, No. 2 | Page 7

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. 7