Source · HSSIB Patient Safety Investigation
Delayed recognition of acute aortic dissection
Published 2 June 2021
Launched 20 July 2017
Published
HSIB Legacy
Emergency care
Communication and decision making
Acute aortic dissection is a relatively rare but life-threatening condition. It requires rapid recognition and urgent treatment in a specialist centre. The symptoms and signs can be confusing and aortic dissection may be mistaken for other conditions, leading to delay in diagnosis.
Summary
2 recommendations
3 observations
1 action
2 of 2 responded
Safety Recommendations
R/2020/066
Manchester Triage International Reference Group
It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.
The Manchester Triage International Reference Group has implemented the recommendation by adding 'aortic pain' as a discriminator to the Manchester Triage System for chest, back, abdominal pain, and collapse, with a clear definition, launched worldwide.
Response received 17 April 2020
As recommended, we considered the addition of ‘aortic pain’ as a discriminator in the Manchester Triage System (MTS). We have added this not only to the chest pain chart but also to the charts for back pain, abdominal pain and collapse. The definition is: ‘The onset of symptoms is sudden and the leading symptom is severe abdominal or chest pain. The pain may be described as sharp, stabbing or ripping in character. Classically aortic chest pain is felt around the sternum and then radiates to the shoulder blades, aortic abdominal pain is felt in the centre of the abdomen and radiates to the back. The pain may get better or even vanish and then recur elsewhere. Over time, pain may also be felt in the arms, neck, lower jaw, stomach or hips.’ The update has been launched worldwide for use by all countries who have implemented (MTS) for face-to-face and telephone triage. It has been made available in an update document on our website: www.triagenet.net . It will also be updated at next reprint in our published text books. Response received on 17 April 2020.
R/2020/067
Royal College of Emergency Medicine (‘RCEM’)
It is recommended that the Royal College of Emergency Medicine, together with the Royal College of Radiologists, develops, deploys and evaluates a national evidence-based process to detect and manage patients with acute aortic dissection presenting to emergency departments. The process should form part of a wider strategy for managing non-cardiac chest pain in the emergency department.
The Royal Colleges are developing national evidence-based guidance and a process for detecting and managing acute aortic dissection in emergency departments, forming a working group to publish guidance in 2021.
Response received 7 October 2020
Both the Royal College of Emergency Medicine and the Royal College of Radiologists extend our sympathies to Richard’s family. We thank them for allowing our medical specialties to learn from Richard’s death. We’re committed to developing and promoting clear guidance for diagnosing and managing patients where acute aortic dissection may be a possibility, but not recognised as such within the emergency department. We are developing an evidence-based process for national roll-out, and the colleges have created a working group to carry out HSIB recommendations. The working group is expecting to publish its guidance in 2021. Evidence-based protocols will provide a framework for consistency. However, Richard’s experience can only be truly avoided by ensuring that all emergency departments can access radiologists to support accurate and timely diagnosis. This, together with the right consultant capacity within emergency departments to help the multi-disciplinary team quickly recognise signs of acute aortic dissection, will enable swift, life-saving action to be taken. Response received on 7 October 2020.
Safety Observations
Observation 1
Observation
There is a lack of detailed and accurate data regarding the incidence and patient outcomes for acute aortic dissection in England, particularly for those patients who do not reach a specialist treatment centre alive. Such data would assist in understanding the true scale of the problem and where any interventions might be directed.
Observation 2
Observation
It would be beneficial if the providers of emergency department triage systems were to consider the addition of ‘aortic pain’ as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.
Observation 3
Observation
Current recommendations for all patients with acute aortic dissection specify immediate measures to control blood pressure and heart rate. Non-specialist hospitals which may dispatch these patients to specialist centres might wish to review their guidance and instructions to staff in this respect. Specialist centres accepting patients with this and other life-threatening conditions could consider developing clear instructions for dispatching hospitals regarding preparation and transfer of patients, in line with best practice.
Safety Actions
Action 1
Action
In release 18, NHS Digital has amended the content of the NHS Pathways algorithm used for telephone triage of patients, to help improve recognition of chest pain likely to be associated with acute aortic dissection.