The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. Although sudden severe chest or back pain is the most common symptom, the picture can vary or mimic other conditions, which may lead to an incorrect diagnosis or delays in recognising a life-threatening condition which needs urgent treatment.
The aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital.
The potential impact of delays in recognising such a serious condition was demonstrated by the case that triggered the investigation. Richard, a fit and healthy 54-year old man, arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey.
Risks in diagnostic process
The HSIB investigation identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition.
It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. The investigation explored decision-making processes in the emergency department and ways in which these might be improved, particularly when the diagnosis is uncertain.
As a result, two safety recommendations have been made to help improve the recognition of acute aortic dissection.
The first is to add ‘aortic pain’ to the list of possible presenting features included in the triage systems used to prioritise patients attending emergency departments.
The second recommends the development of an effective national process to help staff in emergency departments detect and manage this condition.
Dr Stephen Drage, Director of Investigations at HSIB, said “Our investigation found that delay in the diagnosis of acute aortic dissection occurs in up to 40% of cases. This is of particular concern because a dissection is like a ‘ticking time bomb’ for the patient but the diagnosis is often not immediately obvious to staff in the emergency department.
“Our safety recommendations are aimed at helping staff in busy hospitals to consider the possibility and ensure that it is explored in the right way. A common strategy for emergency departments across the country should help improve detection and management of aortic dissection, providing a systematic approach to manage patients with chest pain where a cardiac diagnosis has been ruled out.
“Richard’s case illustrated just how insidiously an acute aortic dissection can progress and how devastating the outcome can be. Improving the processes for detecting this life-threatening condition will allow patients to be transferred rapidly to the specialist care that could save their life.”
Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years.
“Aortic Dissection kills more people in the UK each year than road traffic accidents. Many of these deaths are due to misdiagnosis and delay. Now it’s time for action, to prevent the unnecessary deaths that continue to occur in UK A&E departments. We will be seeking an early meeting with the Secretary of State for Health and the Presidents of the Royal College of Emergency Medicine and the Royal College of Radiologists, to understand how HSIB’s recommendations are going to be implemented.”
Read the report
For more information, including the safety recommendations in full, download and read the ‘delayed recognition of acute aortic dissection’ report.