Time critical diagnosis and transfer of patients with acute type a aortic dissection in the United Kingdom – a need to define standards?

Introduction Type A aortic dissections are a surgical emergency, with roughly 2500 cases per year in England (1). About 20% of patients die before reaching a hospital and about 50% die before reaching a specialist centre, with reported delays in diagnoses in around 16 – 40% of cases (1). There is little knowledge about current logistics and practise by cardiac anaesthetic centres in the UK. We therefore conducted a survey, supported by the Association for Cardiothoracic Anaesthesia and Critical Care (ACTACC) network. Methods We sent a 17-question survey to 28 ACTACC link-persons in UK cardiac centres in February 2020. Data was collected and collated using the web-based survey platform “Survey Monkey” (Palo Alto, CA). Results The response rate was 68% (n=18). The majority of centres (73%, n=13) shared aortic dissection services with 1-3 other cardiac centres in their region. A majority of centres (n=13, 72%) reported that the maximum duration of ambulance transfer within their region was 90 minutes or less. In the remaining centres travel times were between 2-6 hours. A small majority of the respondents felt that there was often or always a delay in diagnoses and transfer of Type A aortic dissection patients to cardiothoracic centres (n=11, 61% and n=10, 56% respectively). Monitoring and blood pressure treatment of patients with acute Type A aortic dissections were only sometimes or rarely appropriate, as indicated by the majority of respondents with n=12 (67%) and n=15 (83%), respectively. The majority reported that escorting personnel was only sometimes or rarely experienced or trained (n=13, 72%). Half of the respondents assessed handover as often or always appropriate (n=9, 50%). The ideal destination at arrival for patients with acute Type A aortic dissections was the critical care unit in the majority (n=12, 67%) of centres, with 5 centres preferring theatre (28%). There was agreement from respondents that guidelines regarding the transfer of acute Type A aortic dissection patients would be beneficial. Discussion This survey of UK cardiac centres shows that the majority of centres already centralise treatment of Type A aortic dissection patients by sharing responsibilities. Furthermore, it reflects the observation by the majority of ACTACC link persons that there may be room for improvement of a timely diagnosis, transfer times, monitoring, and training and experience of escorting personnel. In the future a national prospective audit of acute Type A dissection cases in the UK will be necessary to further assess timely diagnoses and quality of transfer-related variables in individual patients with the view of elucidating how to potentially reduce the high incidence of pre-hospital deaths of patients with acute Type A aortic dissection. This survey was conducted before the COVID-19 pandemic. A future audit would help to assess NHS treatment of acute Type A aortic dissections after the pandemic peak.