Subject(s)
Aortic Aneurysm, Abdominal/surgery , Blood Vessel Prosthesis Implantation , Clinical Reasoning , Elective Surgical Procedures , Endovascular Procedures , Patient Selection , Practice Guidelines as Topic/standards , Aortic Aneurysm, Abdominal/epidemiology , Blood Vessel Prosthesis Implantation/methods , Blood Vessel Prosthesis Implantation/standards , Decision Making, Shared , Elective Surgical Procedures/methods , Elective Surgical Procedures/standards , Endovascular Procedures/methods , Endovascular Procedures/standards , Humans , Quality Improvement , Risk Assessment , United Kingdom/epidemiologyABSTRACT
AIM: To explore areas of consensus and disagreement concerning the interhospital transfer of patients with a clinical diagnosis of ruptured abdominal aortic aneurysm. METHODS: A three-round Delphi questionnaire approach was used among vascular and endovascular surgery and emergency medicine specialists to explore patient characteristics and clinical management issues for emergency interhospital transfer. Analysis is based on 38 responses to rounds 2 and 3 (19 vascular surgeons, 6 interventional radiologists, 13 emergency care specialists) with agreement reported when 70% of respondents were in agreement. RESULTS: Initially there was agreement that transfer patients should be <85 years of age, either alert or with fluctuating consciousness, with moderate or minimal systemic disease, needing no/some help with daily living. Round 3 clarified that patients requiring inotropes and those institutionalised for mental infirmity should be transferred. Those with cardiac arrest in current episode should not be transferred. There was no agreement as to whether those institutionalised with physical infirmities, unconscious/intubated patients or those with severe systemic disease should be transferred. Speed was accepted as important, with agreement for specialty trainees to arrange transfer if consultants were not on site. Consultant-consultant discussion was recommended for patients with severe systemic disease. CT confirmation of diagnosis was considered unnecessary before transfer but ultrasound assessment was desirable, and transfers should not be delayed by waiting for specific tests. There was no agreement about blood tests and ECG before transfer or whether blood should accompany the patient being transferred. There was no agreement as to whether specific staff/facilities needed to be in place at the specialist hospital. A systolic blood pressure ≥70 mm Hg was sufficient for transfer without the need for intravenous fluids unless deterioration occurred. CONCLUSIONS: There is broad agreement about the type of patient who should be eligible for transfer but disagreements about patient management before and during transfer remain.
