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The Impact of Interdisciplinary Protocols for Managing Patients with Acute Aortic Dissection in the Emergency Department: A Systematic Review Protocol

[version 1; peer review: awaiting peer review]
Xuemei Gong
https://orcid.org/0009-0003-3335-7217
1, Philip Hardie
https://orcid.org/0000-0003-1950-5095
1, Louise Doyle1, Yu Yan1, Zhuming Bao
https://orcid.org/0000-0001-6506-3633
2, Catherine McCabe1
Xuemei Gong
https://orcid.org/0009-0003-3335-7217
1, Philip Hardie
https://orcid.org/0000-0003-1950-5095
1, [...] Louise Doyle1, Yu Yan1, Zhuming Bao
https://orcid.org/0000-0001-6506-3633
2, Catherine McCabe1
PUBLISHED 31 Mar 2026
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW

Abstract

Background

Acute aortic dissection (AAD) is characterised by sudden onset, rapid progression, and exceptionally high mortality, making it significantly more life-threatening than cerebral infarction or malignant neoplasms. Despite advances in imaging and surgical techniques, many patients still do not receive timely and optimal care, particularly regarding the interval from emergency department (ED) arrival to surgery. Diagnostic delays, poor interdepartmental communication, and fragmented protocols are major contributors to treatment delay and adverse outcomes. Therefore, the development of an interdisciplinary protocol is essential to optimise diagnostic and therapeutic processes, shorten treatment time, and improve patient outcomes. This review aims to synthesise the evidence to evaluate the effectiveness of interdisciplinary protocols in improving clinical outcomes.

Methods

This protocol was prospectively registered on PROSPERO (CRD420261284772) and will be reported in line with the PRISMA-P guidelines. Searches of the Cochrane Library, CINAHL, MEDLINE, Scopus, EMBASE, and the PROSPERO register will be conducted to identify comparative study designs, including randomised controlled trials (RCTs), quasi-experimental studies, and observational comparative studies (e.g. cohort and case-control studies), evaluating the effects of interdisciplinary protocols on clinical outcomes in patients with AAD. Screening and data extraction will be conducted independently by two reviewers. The risk of bias of included studies will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist. If sufficient clinical and methodological homogeneity is identified, a meta-analysis will be conducted; otherwise, the findings will be presented in a narrative synthesis.

Conclusions

This systematic review will explore the effects of interdisciplinary protocols for patients with AAD to inform best practice. The findings may inform future protocol development, particularly in the context of time-critical emergency care.

Keywords

Aortic Dissection, Multidisciplinary Care Team, Protocol, Emergency Care

Corresponding author: Xuemei Gong
Competing interests: No competing interests were disclosed.
Grant information: Health Research Board (Ireland).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:  © 2026 Gong X et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Gong X, Hardie P, Doyle L et al. The Impact of Interdisciplinary Protocols for Managing Patients with Acute Aortic Dissection in the Emergency Department: A Systematic Review Protocol [version 1; peer review: awaiting peer review]. HRB Open Res 2026, 9:28 (https://doi.org/10.12688/hrbopenres.14370.1) First published: 31 Mar 2026, 9:28 (https://doi.org/10.12688/hrbopenres.14370.1) Latest published: 31 Mar 2026, 9:28 (https://doi.org/10.12688/hrbopenres.14370.1)

Introduction

Acute aortic dissection (AAD) is characterised by sudden onset, rapid progression, and exceptionally high mortality, making it significantly more life-threatening than cerebral infarction or malignant neoplasms. Globally, the incidence of aortic dissection is estimated at 2.6 - 3.5 cases per 100,000 person-years,1–3 with a rate of 3.71 per 100,000 person-years in Han Chinese populations.4 AAD is associated with high mortality among cardiovascular diseases.5 The mortality rate of AAD is closely linked to treatment timeliness, increasing by 1% - 2% per hour.6 Specifically, mortality rates within 48- 72 hours, one week, and two weeks are 50%, 66%, and 80%, respectively.7 Surgical intervention remains the primary treatment for AAD8; without surgery, the mortality rate reaches 75% within two weeks.9 Therefore, reducing the door-to-surgery time is essential for patients with AAD.

The door-to-surgery time refers to the interval between a patient's arrival at the emergency department (ED) and the start of surgery.10 The International Registry of Acute Aortic Dissection (IRAD), a collaborative research registry comprising 58 major referral centres across 13 countries, reports a median door-to-surgery time of 8.3 hours: 4.3 hours from door to diagnosis, and an additional 4.0 hours from diagnosis to surgery.11,12

The management of AAD is complex and involves multiple clinical disciplines, highlighting the need for emergency guidelines based on interdisciplinary collaboration. This review aims to synthesise the evidence to evaluate the effectiveness of interdisciplinary protocols in improving clinical outcomes.

Review questions

  • 1. What is the impact of interdisciplinary protocols on key time-based metrics, including door-to-diagnosis and diagnosis-to-surgery times, for patients presenting with suspected AAD in the ED?

  • 2. How does the implementation of interdisciplinary protocols for AAD affect patient outcomes, including in-hospital or short-term mortality and morbidity (e.g. neurological, cardiovascular, or surgical complications), compared to standard care without such protocols?

  • 3. What are the key components of interdisciplinary protocols for AAD management, and what barriers and facilitators of implementation are reported across different healthcare settings?

Methods

A systematic review and meta-analysis, where appropriate, will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews.13 This systematic review was prospectively registered on PROSPERO (CRD420261284772). This protocol is reported in line with the PRISMA-P guidelines.14

Search strategy

An academic information specialist librarian from the institution's library, experienced in supporting systematic reviews, was involved in developing the search strategies. Systematic searches will include CINAHL, the Cochrane Library, MEDLINE, Scopus, and EMBASE. A search of grey literature will be conducted by running keyword searches in OpenGrey, CADTH Grey Matters, and web-based clinical trial registries. Additionally, citation tracking will be employed to identify additional relevant articles by reviewing the reference lists of included studies to uncover additional sources that may have been missed by the search. No restrictions will be placed on language or year of publication. The search strategy combines Medical Subject Headings (MeSH) and free-text keywords relating to acute aortic dissection, interdisciplinary protocols, and emergency care. Detailed search strategies are provided in Appendix 1.

Study selection

All retrieved citations will be imported into Covidence systematic review software for study management and duplicate removal.15 The remaining citations will undergo title and abstract screening by two independent reviewers (XG and YY) against the predefined inclusion and exclusion criteria. Full texts of citations identified as eligible will be retrieved and independently screened by the same two reviewers (XG and YY). Any disagreements will be resolved by a third reviewer (ZB).

Eligibility criteria

Eligibility criteria will be established based on the PICOS (population, intervention, comparison, outcomes, and study design) framework. The inclusion and exclusion criteria will be summarised in Table 1.

Table 1. PICOS framework.

CriteriaInclusionExclusion
Population

  • 1. Adults aged ≥18 years;

  • 2. Patients diagnosed with AAD according to diagnostic criteria;

  • 3. Patients admitted to the ED including those transferred directly to cardiovascular or cardiothoracic surgical services.

  • 1. Patients under 18 years;

  • 2. Patients with a diagnosis other than AAD (e.g.intramural haematoma, penetrating aortic ulcer);

  • 3. Patients not presenting to the ED.

InterventionInterdisciplinary Protocols.Non-interdisciplinary Protocols.
ComparatorStandard care or no protocol.Studies without a comparator group.
Outcomes

  • 1. Time-based metrics (e.g. door-to-diagnosis, diagnosis-to-surgery, or door-to-surgery time);

  • 2. Mortality (in-hospital or short-term);

  • 3. Morbidity (e.g. neurological, cardiovascular, or surgical complications).

Studies not reporting time-based metrics, mortality, or morbidity.
Study designRCTs, quasi-experimental studies, and observational comparative studies (e.g., cohort and case-control studies).Systematic reviews, case reports, case series, descriptive studies, and studies without a comparator group.

Data extraction

Two reviewers (XG and YY) will independently extract data from the included studies using the standardised data extraction tools available in JBI SUMARI.16 The accuracy and completeness of extracted data will be verified by a third reviewer (ZB).

Experimental study designs (RCTs and quasi-experimental studies) will be extracted using the JBI data extraction form for experimental studies (Appendix 2). Observational study designs (cohort and case-control studies) will be extracted using the JBI data extraction form for observational studies (Appendix 3).

Data extraction will be conducted in accordance with the methodological guidance outlined in the JBI Manual for Evidence Synthesis for effectiveness reviews. Where studies present unclear, missing, or incompletely reported data, we will contact the study authors to obtain additional information.

Risk of bias assessment and GRADE evaluation

Risk of bias will be assessed independently by two reviewers (XG and YY) using design-specific JBI critical appraisal checklists,13 with disagreements resolved by a third reviewer (ZB). Given the inclusion of multiple study designs, appropriate JBI tools will be applied according to study type: the JBI checklist for RCTs (Appendix 4), the JBI checklist for quasi-experimental studies (Appendix 5), and the relevant JBI checklists for observational studies, including cohort studies (Appendix 6) and case-control studies (Appendix 7).

Each checklist addresses key sources of bias related to study design, participant selection, measurement, confounding, and statistical analysis. Items will be rated as “yes,” “no,” “unclear,” or “not applicable” in accordance with JBI guidance. No numerical summary score will be calculated.

The certainty of evidence for each outcome will be assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.17 The certainty of evidence will be rated as high, moderate, low, or very low.17

Data synthesis

If clinical and methodological homogeneity is identified, a meta-analysis will be conducted using JBI SUMARI.16

For continuous outcomes, means and standard deviations (SDs) will be extracted, and effect sizes will be calculated using mean differences (MD) with corresponding 95% confidence intervals (CIs). For dichotomous outcomes, event numbers and total sample sizes will be extracted, and risk ratios (RR) with 95% CIs will be calculated. A random-effects model will be applied to account for expected variability between studies. Heterogeneity will be assessed through visual inspection of forest plots and quantified using the chi-square (χ2) test and the I2 statistic. If more than ten studies are included, funnel plots will be generated to explore potential publication bias.

Where substantial clinical or methodological heterogeneity exists, or where data are insufficient to support quantitative pooling, findings will be synthesised narratively. Two reviewers (XG and YY) will independently conduct data synthesis. Any discrepancies will be resolved through discussion or, if necessary, by a third reviewer (ZB).

Study status

A preliminary search of the literature has been conducted, and citations are managed in Covidence.

Discussion

Given the increasing number of studies evaluating interdisciplinary protocols for AAD, this systematic review aims to synthesise the available evidence on interdisciplinary protocols to inform best practice. The findings will support evidence-based decision-making in emergency and cardiovascular nursing, inform best practice in the early management of AAD, contribute to the development and optimisation of interdisciplinary protocols, and identify gaps in the current evidence to guide future research and service improvement.

Strengths and limitations

This systematic review will follow the JBI Manual for Evidence Synthesis. To enhance transparency and minimise selective reporting, this review has been prospectively registered on PROSPERO and will include searches for grey literature and trial registries to reduce publication bias. Title and abstract screening, full-text review, and methodological quality assessment will be conducted independently by two reviewers, with disagreements resolved through discussion. Nevertheless, exclusion of ongoing or unpublished studies with unavailable results may introduce publication bias.

Ethics and dissemination

Ethics approval is not required for this systematic review. This protocol is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines.14

This study aims to provide empirical evidence for optimising the early management of AAD, thereby advancing emergency and cardiovascular nursing while furthering the development of evidence-based practice.

The findings will be disseminated through publication in high-impact, peer-reviewed journals pertinent to emergency medicine and cardiovascular nursing. Additionally, the research outcomes will be presented at national and international academic conferences, including the International Council of Nurses Congress and the ESC Cardiovascular Nursing Conference, promoting knowledge sharing and encouraging interdisciplinary collaboration.

Data availability

Underlying data

No underlying data are associated with this article.

Extended data

Figshare: Extended data for the impact of interdisciplinary protocols for managing patients with acute aortic dissection in the emergency department: a systematic review protocol. https://doi.org/10.6084/m9.figshare.31376509.18

This project contains the following data:

  • • Supplementary file 1: PRISMA-P 2015 checklist

  • • Supplementary file 2: Search strategy (Appendix 1)

  • • Supplementary file 3: Data extraction forms (Appendix 2–3)

  • • Supplementary file 4: Risk of bias assessment forms (Appendix 4–7)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

  • 1.  Erbel R, Aboyans V, Boileau C, et al.: 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Eur. Heart J. 2014; 35(41): 2873–2926.
  • 2.  Bossone E, Eagle KA, Isselbacher EM: Acute aortic syndromes: Diagnosis and management, an update. Eur. Heart J. 2018; 39(9): 739–749.
  • 3.  Isselbacher EM, Preventza O, Black JH, et al.: 2022 ACC/AHA guideline for the diagnosis and management of aortic disease. J. Am. Coll. Cardiol. 2022; 80(24): e223–e393.
  • 4.  Tang L, Liu Y, Wang L, et al.: Epidemiology of aortic dissection in China: A nationwide study. Heart. 2021; 107(10): 819–824.
  • 5.  Harris KM, Strauss CE, Duval S, et al.: Mortality and morbidity in acute aortic syndromes. J. Am. Coll. Cardiol. 2022; 79(23): 2263–2276.
  • 6.  Nienaber CA, Clough RE: Management of acute aortic dissection. Lancet. 2015; 385(9970): 800–811. Publisher Full Text
  • 7.  Yadav PK, Singh S, Kumar A: Mortality trends and risk factors in patients with acute aortic dissection: A systematic review. Heart Lung. 2021; 50(5): 689–696.
  • 8.  Gawinecka J, Schönrath F, von Eckardstein A : Acute aortic dissection: Pathogenesis, risk factors and diagnosis. Swiss Med. Wkly. 2017; 147(3334): w14489. Publisher Full Text
  • 9.  Erbel R, Aboyans V, Boileau C, et al.: 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Polish Heart Journal (Kardiologia Polska). 2014; 72(12): 1169–1252.
  • 10.  Fandino W, Gilbey T, Milne B, et al.: Factors associated with symptom-to-surgery time in patients undergoing surgical repair for acute type A aortic dissection: an exploratory analysis from a prospective cohort study. BMJ Surgery, Interventions, & Health Technologies. 2025 May 28; 7(1): e000304.
  • 11.  Froehlich JB, Isselbacher EM, Eagle KA, et al.: Timing of surgery and mortality in acute type A aortic dissection: Insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2018; 138(15): 1690–1700.
  • 12.  Harris KM, Strauss CE, Eagle KA, et al.: Correlates of delayed recognition and treatment of acute type A aortic dissection: the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2011; 124(18): 1911–1918.
  • 13.  Aromataris E: JBI manual for evidence synthesis. Adelaide: JBI; 2020. Reference Source
  • 14.  Shamseer L, Moher D, Clarke M, et al.: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. BMJ. 2015; 350: g7647. PubMed Abstract | Publisher Full Text
  • 15.  Veritas Health Innovation: Covidence systematic review software [computer software].2023. Reference Source
  • 16.  Munn Z, Aromataris E, Tufanaru C, et al.: The development of software to support multiple systematic review types: the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Int. J. Evid. Based Healthc. 2019; 17(1): 36–43. PubMed Abstract | Publisher Full Text
  • 17.  Schünemann H, Brożek J, Guyatt G, et al.: GRADE handbook for grading quality of evidence and strength of recommendations. The GRADE Working Group.2013.
  • 18.  Gong X: The impact of interdisciplinary protocols for managing patients with acute aortic dissection in the emergency department: a systematic review protocol. [Dataset]. Figshare. 2026. Publisher Full Text

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Gong X, Hardie P, Doyle L et al. The Impact of Interdisciplinary Protocols for Managing Patients with Acute Aortic Dissection in the Emergency Department: A Systematic Review Protocol [version 1; peer review: awaiting peer review]. HRB Open Res 2026, 9:28 (https://doi.org/10.12688/hrbopenres.14370.1)
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