RACE-aortic dissection process flow design and the AAD team

Beginning in 2013, the RACE-Aortic Dissection (RACE-AD) process flow map was implemented at our hospital, in order to improve the efficiency of diagnosis, transfer, and management of patients with AAD. The RACE-AD program was modeled after, and borrows its name from, the Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE-STEMI) program, a statewide program implemented in 2006 that outlined prehospital care protocols for the rapid triage and transport of STEMI patients directly to percutaneous coronary intervention (PCI)-capable facilities (7). However, it should be noted that there are no official regulatory policies or hospital agreements in North Carolina which instruct the disposition of acute dissection patients. The RACE-AD program therefore represents an internal process improvement initiative intended to improve the regional outcomes of AAD patients and increase institutional AAD volume through re-allocation of hospital resources and enhanced communication with affiliated and non-affiliated hospitals throughout the Southeast region.

The key features of the RACE-AD transfer protocol include immediate communication between the referring physician and the attending aortic surgeon on-call, guided recommendations for prehospital imaging, laboratory, and hemodynamic management, direct patient transfer to the operating room (OR) or cardiothoracic intensive care unit (CTICU), lack of hospital bed divert for any suspected AAD patients, and OR standby within 30 minutes of AAD team activation (Figure 1). The AAD team is led by the aortic attending on-call and activation of the AAD team elicits a batch page to the aortic attending, CT fellow, CT anesthesia attending, CTICU charge nurse, CT OR charge nurse, OR front desk, CTICU attending, and perfusionist on-call, as well as the institutional International Registry of Acute Aortic Dissection (IRAD) coordinator and RACE-AD project manager. Patients requiring emergent operation are transported directly to the OR, bypassing the emergency department and CTICU, and all surgical staff members of the AAD team are expected to have a 30 minute response time. Following completion of an ATAAD repair the aortic attending calls the referring physician to inform them of the results and provide feedback and recommendations for future transfers, thereby strengthening the referral network. A similar RACE-AD process flow map was created to expedite the diagnosis and management of patients presenting directly to our ED with suspected AAD.

RACE-Aortic Dissection process flow map for patient transfers.