HSSIB impact: life-saving difference for acute aortic dissection patients

Aortic dissection is a life-threatening medical emergency involving a tear in the body’s main artery – the aorta – which carries blood from the heart to the brain, limbs and vital organs. There are around 4,000 cases of aortic dissection in the UK each year. The condition causes more UK deaths than road traffic accidents.

There are two HSSIB reports that have made a life-saving difference for acute aortic dissection patients:

• Delayed recognition of acute aortic dissection (published in 2020)
• Transfer of critically ill adults (published in 2019)

We at Aortic Dissection Awareness UK & Ireland (the national patient charity) were pleased to be invited to work on these investigations. We welcomed the two reports and their safety recommendations, which have had a significant impact on patient safety, as we are now able to demonstrate with supporting evidence.

Delayed recognition of acute aortic dissection

It’s five years now since HSSIB published its investigation report into the death of a 50-year-old man, Richard, from an acute aortic dissection. Here at the national patient charity, we’ve been reviewing the impact of this investigation in the context of our THINK AORTA campaign and recently-published data. I would like to share our findings with you.

First-ever national guidance

As a direct response to the HSSIB report, the Royal College of Emergency Medicine and the Royal College of Radiologists produced their first-ever joint national guidance: ‘Diagnosis of Thoracic Aortic Dissection in the Emergency Department’, published in November 2021. This guidance has been widely communicated and has become the definitive source of national best practice in diagnosing acute aortic dissection. The guidance was updated in January 2024 with new insights emerging from clinical experience and research in this field.

Manchester Triage System

The HSSIB report’s recommendation to update the Manchester Triage System, used in most emergency departments, to include ‘aortic pain’ was also implemented.

Human factors

Finally, the report’s focus on the human factors associated with this diagnosis and its inclusion of our THINK AORTA diagnostic poster gave significant credibility to the approach being taken to educate clinicians to “Think Aorta” and on the importance of clinician gestalt (their overall clinical impression) in diagnosing the condition.

National improvement in diagnosis

The above three outcomes, in combination, contributed to a significant national improvement in the diagnosis of acute aortic dissection, which we now have the data to demonstrate.

The 2023 National Adult Cardiac Surgery Audit, produced by the National Institute for Cardiovascular Outcomes Research (NICOR), looked at the number of people who have emergency aortic surgery. It found that over a 9-year period, emergency aortic surgery cases (almost all of which are acute Type A aortic dissection), increased by 68%, so approximately 250 more patients per year were benefitting from access to life-saving surgery.

Significantly, the auditors said:

“There has been concern that the diagnosis is often missed or delayed. As a result, several publicity campaigns (e.g., ‘Think Aorta’) have aimed to raise awareness of the diagnosis by primary care and emergency physicians such that more patients are transferred to specialist cardiac surgical centres for treatment. It seems likely that these have been successful in raising the number of cases (rather than there being a significant increase in the prevalence of the disease in the UK).”

The 2024 National Adult Cardiac Surgery Audit (NACSA) report updated this picture and found an 82% increase in cases over a 10-year period, which equates to 315 additional patients per year receiving life-saving emergency aortic surgery. Many of these patients subsequently join the national patient charity and tell us their stories of diagnosis, surgery and survival.

Transfer of critically ill adults

The scope and impact of the transfer of critically ill adults report was broader than the acute aortic dissection report, however, it did result in two significant changes in the way acute aortic dissection patients are transferred.

During the COVID-19 pandemic, UK Ambulance Trusts commissioned critical care ambulance services, primarily to transfer acute COVID-19 cases to hospitals with available intensive care unit (ICU) beds. These consultant-led services essentially provide an ICU bed in the back of an ambulance. As a result of the HSSIB report, agreement was reached that acute aortic dissection patients are eligible for a critical care ambulance.

While the number of such ambulances remains limited and varies across regions, access to one greatly increases patient safety during transfer to an aortic specialist centre for surgery. The RETRIEVE service in South West England and the ACCESS service in London have led the way in implementing this change in transfer policy for aortic dissection patients.

Increased recognition of the problem of safe transfer led clinicians and clinical academics to collaborate with us on the TRAVERSING study, which delivered a national consensus on the principles of safe transfer of acute aortic dissection patients. This was the second piece of national guidance arising directly from HSSIB’s work on this topic.

Conclusion

In our view, as the national patient charity, these impactful patient safety investigation reports have contributed to a significant improvement in the care of acute aortic dissection patients and the saving of many hundreds of lives annually.

This excellent, collaborative work has made a real, life-saving difference to patients.