ORIGINAL ARTICLE

Telemedicine network Program for reperfusion of Myocardial infarction

Programa en red para la reperfusión del infarto con telemedicina

 

ALEJANDRO SILBERSTEIN, MAXIMILIANO DE ABREU^{MTSAC, 1}, JAVIER MARIANI^{MTSAC, 1}, DIEGO KYLE1, GABRIEL GONZÁLEZ VILA MONTE^{†, 1}, RICARDO SARMIENTO^{MTSAC, 1}, CARLOS D. TA JER^{MTSAC, 1}, Researchers of “EL Cruce” Network for the Care of Acute Coronary Syndromes

SEE RELATED ARTICLE: Rev Argent Cardiol 2014;83:185. http://dx.doi.org/10.7775/rac.v83i3.6392

Received: 12/05/2014 - Accepted: 03/11/2015

Address for reprints: Maximiliano de Abreu - Av. Calchaquí 5401 - Florencio Varela. Provincia de Buenos Aires, Argentina - Tel. 54 11 4210-9000 e-mail: maxideabreu@gmail.com

^MTSAC Full Member of the Argentine Society of Cardiology
¹ Hospital de Alta Complejidad en Red El Cruce - Néstor Kirchner
^† To apply as Full Member of the Argentine Society of Cardiology
Financial Support: Carrillo-Oñativa scholarships. National Health Research Council. National Ministry of Health.

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ABSTRACT

background: Early management of myocardial infarction in the area of public health requires the integration of specific programs for the coordination of healthcare services.
Objective: The aim of this study was to evaluate the impact on delay times and reperfusion rate of a comprehensive program for the reperfusion of myocardial infarction in a hospital network of the Southern Greater Buenos Aires.
Methods: The network consists of six low-mid-complexity hospitals and a third-level referral center with 24-hour cath-lab. Stage 1 of the program (2009-2010) evaluated the existing barriers to reperfusion; Stage 2 (2011-2013) implemented the progressive incorpora-tion of improvements and Stage 3 assessed the program (2013-2014) complemented with fellows in each hospital. Program impact was evaluated by the proportion of patients reperfused and time to its implementation.
results: A total of 432 patients referred from the network were hospitalized with diagnosis of ST-segment elevation myocardial infarction. Mean age was 56±9 years and 83.3% were men. The proportion of reperfused patients progressively increased: S1 60.7%, S2 69% and S3 78%, p for trend=0.01. Time to reperfusion decreased significantly between S1 and S3, from 120 minutes (IQR 55-240) to 90 minutes (IQR 35-150), p=0.04, with a median reduction of 30 minutes in the door-to-balloon and door-to-needle times. Conclusions: The application of a program for myocardial reperfusion based on the diagnosis of barriers was associated with 28.5% increase in reperfusion, and a significant reduction in the implementation times. This public network model built on algorithms adapted to local barriers may contribute to improve the care of myocardial infarction in our country.

Key words: Myocardial Infarction -Myocardial Reperfusion- Telemedicine - Community Networks

RESUMEN

introducción: La atención del infarto en sus primeras horas en el ámbito público requiere la coordinación de los servicios asisten-ciales integrando programas específicos.
Objetivo: Evaluar el impacto sobre los tiempos de demora y la tasa de reperfusión de la instrumentación de un programa integral para la reperfusión del infarto en una red hospitalaria pública del conurbano sur bonaerense.
Material y métodos: La red está compuesta por seis hospitales de baja-mediana complejidad y un centro de tercer nivel con disponibilidad de hemodinamia las 24 horas. En la Etapa 1 (E1) del programa (2009-2010) se evaluaron las barreras existentes para la reperfusión, en la Etapa 2(E2) (2011-2013) se incorporaron progresivamente las medidas y en la Etapa 3(E3) (2013-2014) se evaluó el programa complementado con becarios en cada hospital. Se midió el impacto del programa en la proporción de pacientes reper-fundidos y tiempos a su implementación.
resultados: Se internaron un total de 432 pacientes derivados de la red con diagnóstico de infarto con elevación del segmento S T. Edad 56 (± 9) años, hombres 83,3%. La proporción de pacientes reperfundidos aumentó progresivamente: E1 60,7%, E2 69% y E3 78%, p de tendencia=0,01. Los tiempos a la reperfusión se redujeron significativamente entre la E1 y la E3, de 120 minutos (IIC 55-240) a 90 minutos (IIC 35-150), p=0,04, con una reducción de la mediana de 30 minutos tanto en el tiempo puertabalón como puerta-aguja.
Conclusiones: La implementación de un programa basado en el diagnóstico de barreras se asoció con un incremento en la proporción de reperfusión del 28,5% y con una reducción significativa de los tiempos en la implementación. Este modelo de red para la atención pública basado en algoritmos adaptados a la problemática local puede contribuir a mejorar la asistencia del infarto en nuestro país.

Palabras clave: Infarto del miocardio- Reperfusión miocárdica - Telemedicina - Redes comunitarias

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IQR Interquartile range
PPCI Primary percutaneous coronary intervention
S1 Stage 1
S2 Stage 2
S3 Stage 3
STEAMI ST-segment elevation acute myocardial infarction

 

INTRODUCTION

Myocardial infarction is a frequent disease with el-evated mortality rates. According to national statis-tics, 30% of deaths in Argentina can be attributed to cardiovascular causes, and in epidemiological estima-tions, approximately 40,000 patients per year are hos-pitalized for myocardial infarction. (1, 2) In the first hours after infarction different interventions have an impact on mortality reduction, the main one being reperfusion therapy. (3) Scientific publications based on multicenter registries and referral networks for the treatment of ST-segment elevation acute myocar-dial infarction (STEAMI) have shown suboptimal re-sults regarding the rate of reperfused patients and the times to its implementation. (4, 5) Existing scientific evidence shows that it is necessary to develop a com-prehensive plan with specific programs for STEAMI treatment to achieve a significant increase in the pro-portion of reperfused patients and a reduction in the times to reperfusion. (6-13) These programs require the initial diagnosis of situations and barriers, plans involving the different participants, the generation of common treatment algorithms, and the application of long-term measures with permanent evaluation of re-sults. (6-11) In our country there is scarce experience in the elaboration of programs based on referral net-works for reperfusion of STEAMI patients.

The aim of our study was thus to evaluate the im-pact of the progressive application of a comprehensive STEAMI reperfusion program on the ratio of reper-fused patients and time delay to reperfusion in a hospital network of the Southern Greater Buenos Aires.

METHODS

An interventional study was designed with pre-and post-in-tervention endpoints. The hospital network was established at the onset of activities in the high complexity hospital in October 2008 and consists of another six low-mid-complexity hospitals of the Southern Greater Buenos Aires (Appendixes 1 and 2). The high-complexity hospital has a cardiovascular intensive care unit, 24-hour cath-lab with primary percuta-neous coronary intervention availability, and cardiovascular surgery. In low-mid-complexity hospitals the emergency is managed by general practitioners, the intensive care units are polyvalent, and lack a proper cath-lab (see Appendix 1). All patients diagnosed with STEAMI admitted to the high-complexity hospital referred from the network hospi-tals between June 2009 and May 2014, were included in the study. Patients referred from centers outside the network and those who presented spontaneously to the high-com-plexity hospital were excluded from the analysis. The study was initiated in June 2009, when the prospective registry of acute coronary syndromes started in the high-complexi-ty hospital, and was divided in three temporal consecutive

stages. The first stage of the program (S1, June 2009 to April 2010) evaluated the existing barriers for reperfusion in the different centers. Qualitative assessments were performed by group interviews with medical directors, chief and staff physicians of the emergency departments belonging to the network hospitals, and quantitative evaluations by time delays to reperfusion during that stage. The main barri-ers were absence of cardiologists in the emergency rooms trained to interpret the electrocardiograms, lack of fibrino-lytics in some emergency rooms, inexperience of clinicians to infuse fibrinolytics, and excessive delay in transfer times due to lack of available ambulances. In the second stage (S2, May 2010 to April 2013), the following measures were progressively implemented, based on the detected barriers and the availability of network resources: a) incorporation of a telemedicine system with available equipments in the hospital network emergency rooms for 24-hour web-based electrocardiogram transmission to the coronary care unit of the high-complexity hospital; b) theoretical-practical talks on the management of patients with chest pain and/or in-farction and fibrinolytic infusion; c) an agreed algorithm for the management of patients consulting for chest pain; d) a specific algorithm for STEAMI, according to onset, exten-sion and clinical involvement, with preference for in-situ thrombolysis, or direct referral for primary percutaneous coronary intervention (PPCI). Extensive infarctions, heart failure, cardiogenic shock or contraindication to fibrinolytic therapy were considered preferential criteria for PPCI refer-ral; and e) a system of private ambulances was incorporated for transfer of PPCI patients in case of delay in the system service. At the beginning of the third stage (S3, May 2013 to May 2014) a physician responsible of program management was appointed at each second-level center, financed by a re-search scholarship for multicenter studies (Carrillo Oñativia Scolarships) of the National Ministry of Health. Since then, the program works with all the implemented measures.

The final endpoints were the rate of reperfused patients and times to reperfusion (door-to-needle and door-to-balloon times) achieved in the network.

statistical analysis

Continuous variables were expressed as mean and standard deviation or as median and interquartile range according to their distribution. Categorical variables were expressed as numbers and percentages. Differences between groups for continuous variables were evaluated with non-parametric tests (Kruskal-Wallis). Categorical variables were compared using the chi-square and Fisher tests. The chi-squared test for trend was used to assess the temporal evolution and the rate of reperfused patients. A two-tailed p value <0.05 was considered as statistically significant for all compari-sons. Statistical analyses were performed with STATA 10.0 (StataCorp L P, College Station, Texas) and Epi-Info 3.5.1. software packages.

Ethical considerations

The study was approved by our hospital Scientific Committee and Ethics Committee. An informed consent was not re-quested, as it was a study based on an intervention to the system and not to individual patients.

RESULTS

A total of 432 patients referred from the network with STEAMI diagnosis were admitted to hospital. Eighty-nine patients were incorporated in S1, 261 in S2 and 82 in S3. Mean age was 55.8±9.4 years and 83.3% were men. Patient flowchart is described in Figure 1. The main characteristics of the patients are detailed in Table 1.

reperfusion

The proportion of patients who presented criteria to receive reperfusion strategies at the time of consulta-tion in the first center was similar in the three stag-es: 87.6%, 87% and 87.8%, respectively, p=0.97. The overall rate of patients treated with some reperfusion strategy was 69%, and progressively increased; in S1: 60.7%, S2: 69% and S3: 78% (p for trend=0.01), with an absolute reperfusion increase of 17.3% and relative increase of 28.5% between S1 and S3 (Figure 2A).

infuence of telemedicine on reperfusion

The use of telemedicine among patients referred for reperfusion increased in the successive stages; in S1: 0%, S2: 19.9% and S3: 54.9%. Independently of the temporal stage, the proportion of reperfused patients was greater when telemedicine was used (78.4% vs. 66.3%; p=0.01).

The analysis of the association between the use of telemedicine and the rate of reperfusion stratified by stages is shown in Table 2.

type of reperfusion

Figure 2B depicts the type of reperfusion used. It can be seen that the increase in the indication of reperfusion strategies applied both to thrombolytic therapy and PPCI.

 

times to reperfusion

Times to reperfusion were progressively reduced. The reduction was significant between S1 and S3: from a median of 120 minutes (IQR 55-240) in S1 to 90 minutes (IQR 35-150) in S3 (p=0.04). Among patients receiving fibrinolytics at the center of origin, the door-to-needle time was significantly reduced, from 75 minutes (IQR 40-194) in S1 to 45 minutes (IQR 30-90) in S3, with a median reduction of 30 minutes (p=0.035) (Figure 3A), increasing the rate of patients undergoing fibrinolysis within the recommended door-to-needle time (<30 min) from 22% in S1 to 36.7% in S3. A similar though not significant trend in door-to-balloon time reduction was observed among patients undergoing PPCI, from 210 minutes (IQR 120-300 minutes) in S1 to 180 minutes (IQR 130-245) in S3, with a median reduction of 30 minutes (p=0.67) (Figure 3B), slightly increasing the rate of patients receiv-ing PPCI within the recommended door-to-balloon time (<90 min) from 5.3% in S1 to 5.9% in S3. The telemedicine system did not have a significant influ-ence on the times to reperfusion (see Figure 3).

DISCUSSION

ST-segment elevation acute myocardial infarction reperfusion therapy is a medical issue that requires a public health system approach due to the necessary planning and logistics for its implementation, and the beneficial effect produced when performed correctly and within the recommended times. (3) The complexity of proper STEAMI treatment, owing to the need of staff in emergency rooms trained for diagnosis and manage-ment, accessible resources to transport patients when telemeDiCine in tHe treatment oF myoCarDial inFarCtion / alejandro silberstein et al.

 

Fig. 2. a: Percent reperfusion by stages. b: Type of reper-fusion in stages 1 and 3. S1: Stage 1, S2: Stage 2. S3: Stage 3.

 

Table 2. stages	Reperfusion	and use of telemedicine, stratifed by
Stage	Use of telemedicine	Reperfused n (%)	Non reperfused n (%)	'
1	no	54 (60.7)	35 (39.3)	-
2	ye s	40 (76.9)	12 (23.1)	0.08
	no	140 (67)	69 (33)
3	ye s	36 (80)	9 (20)	0.3
	no	28 (75.7)	9 (24.3)

required, available 24-hour cath-lab for the treatment of complex cases, etc., has led to the implementation of specific programs in different parts of the world, with satisfactory results in the achievement of a significant increase in the rate of reperfused patients and a re-duction in the time for its implementation. (6-13) The STEAMI treatment network program in our region has been developed following some of the concepts used in other programs, but has been adapted to the needs, barriers and resources of our network. The relatively low rate of reperfused patients and prolonged times recorded prior to the implementation of our program patently demonstrated the existence of significant bar-riers concerning reperfusion. In this regard, our initial results did not markedly differ from those published by other national and international studies. García Escudero et al. and Piombo et al. published the results of a reperfusion network in the City of Buenos Aires in the absence of specific community programs, and showed similar results to our initial data regarding the rate of reperfused patients and time to reperfusion with PPCI. (14-16) Other international studies also showed that in the absence of specific programs to optimize STEAMI treatment, the results were unsatisfactory. Barbagelata et al. evaluated the temporal trend of delays to reper-fusion in trials published between 1993 and 2003 and verified the absence of significant improvement in the door-to-balloon time and time to reperfusion during that decade. (5) McNamara et al. evaluated the temporal evolution of time to reperfusion in myocardial infarction in the United States, and the median door-to-balloon and door-to-needle times presented less than one minute/year variation between 1999 and 2002. (4) In contrast, several publications showed improvement

Fig. 3. Times by stages and type of reperfusion. A: Fibrinolytics. B: Primary percutaneous coronary intervention. S1: Stage 1. S3: Stage 3. S3 (without tele): Stage 3 without telemedicine. S3 (with tele): Stage 3 with telemedicine.

in reperfusion times in different myocardial infarction treatment networks. In all cases, the optimization time resulted from implementing institutional or general programs tending to shorten each stage of the reperfusion process. (6-13) This scientific evidence, added to that of our study, confirms that the development and implementation of specific programs are the main tool to optimize STEAMI treatment.

The potential clinical impact resulting from the application of our program lies in two effects: a sig-nificant increase of 28.5% in the rate of reperfused patients, reaching 78% reperfused patients in S3, and a reduction of 30 minutes in door-to-balloon and door-to-needle times, achieving an absolute increase of 15.3% and relative increase of 56% in the rate of reperfused patients within the recommended times according to the reperfusion method used. We believe that the main impact of the program was based on the significant increase in the percentage of reperfused patients, since the reduction in the time to reperfu-sion, although significant, did not allow an increase in the percentage of reperfused patients within in-hos-pital recommended optimal times, even in S3. In this aspect work is still being performed on the network to optimize these times.

With regard to the method of reperfusion, the algo-rithm agreed with the medical network contemplates a combination of circumstances in which thrombolysis administered in the hospital of origin is the method of choice, considering its availability in all centers from the beginning of the intervention, low cost, shorter implementation time, trained personnel during the program, median difference in the implementation time >90 minutes compared with PPCI, and availabil-ity of rescue PCI in the network, not requiring times so constrained as PPCI. In patients with large in-farcts, or when referral for PPCI can be done in a very short time and the time estimated between consulta-tion and first balloon inflation is less than 90 minutes, the advantages of this methodology are scientifically undeniable. (3)

It is important to analyse the impact of telemedicine implementation. Patients in whom this system was used were more frequently reperfused than referred patients where the system was not used. Moreover, the percentage of patients reperfused with fibrinolytics in the center of origin was higher among patients in whom telemedicine was used. However, the improve-ment in the rate of reperfused patients may be only partially attributable to telemedicine, added to a general improvement of the system, since the increase of reperfusion (approximately 20% between the first and last stage) was greater than the difference between the telemedicine and non-telemedicine groups (10%). It should also be noted that there was also an increase in the reperfusion of patients with no telemedicine. The door-to-balloon and door-to-needle times were not modified significantly by the use of telemedicine.

In our experience the change was remarkable in the last stage with the support of the Carrillo Oña-tivia Scholarship, which helped finance working hours of research fellows in each of the network hospitals. Their activity was associated with a sixfold increase in

the use of the telemedicine system (which will be re-ported separately) and a marked improvement in the times. Cultural and motivational aspects are crucial for the success of any program that focuses on improv-ing the treatment of myocardial infarction.

limitations

Our study has limitations that should be pointed out. The population comprised patients referred to high complexity hospitals. We cannot rule out a low per-centage of non-referred STEAMI patients admitted to the lower-complexity hospitals of the network.

The survey of event times occurring in referral hospitals were conducted by patient questioning, ob-servation of electrocardiogram times, medical records, nursing and clinical reports, and clinical referral sum-maries. We cannot rule out minor differences between reported and real times.

The increase in the rate of reperfusion among patients in whom the telemedicine system was used might be due to the presence of confounding variables, difficult to survey.

CONCLUSIONS

We conclude that the implementation of an acute myocardial infarction reperfusion program in a public hospital network, based on the diagnosis of existing barriers at the local level, was associated with an in-crease of 28.5% in the rate of reperfusion and a sig-nificant reduction in the time to its implementation. This network model for public healthcare based on algorithms adapted to local issues can help improve the treatment of myocardial infarction in our country.

acknowledgements

The authors wish to thank:

Staff physicians and residents of our service for their permanent collaboration in the development of this research.

To all physicians participating in the network hos-pitals.

To the directors of our hospital, Dr. Arnaldo Medina and Dr. Juan Marini, for providing the necessary resources for this research.

Financial support

This study was supported by a grant from the Nation-al Ministry of Health.

Conficts of interest

None declared

(See author´s conflicts of interest forms in the web / Supple-mentary Material)

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6. Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006;355:2308-20. http://doi. org/chmfrc

7. Gibson CM, Pride YB, Frederick PD, Pollack CV Jr, Canto JG, Tiefenbrunn AJ, et al. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J 2008;156:1035-44. http://doi.org/dqsqp3

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12. Kalla K, Christ G, Karnik R, Malzer R, Norman G, Prachar H, et al; Vienna STEMI Registry Group. Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry). Circulation 2006;113:2398-405. http://doi.org/bpz9tz

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APPENDIx 1

second-level centers participating in the network.

Hospital Dr. Isidoro Iriarte (Quilmes),Hospital Dr. Eduardo Oller (San Francisco Solano), Hospital Dr. Arturo Oñativia (Rafael Calzada), Hospital Evita Pueblo (Berazategui),Hospital Lucio Meléndez (Adrogué), Hospital Mi Pueblo (Florencio Varela).

APPENDIx 2

researchers:

Hospital Dr. Isidoro Iriarte: Dra. Karina Brunetti; Hospital Dr. Eduardo Oller: Dr. Pablo Arabarco; Hospital Dr. Arturo Oñativia: Dra. María Cecilia Luzarda; Hospital Evita Pueblo: Dr. Pablo Arabarco; Hospital Lucio Meléndez: Dr. Daniel García; Hospital Mi Pueblo: Dr. Daniel Gonzáles Faro; Hospital El Cruce: Dr. Juan Alfonso, Dra. Pilar Anoni, Dr. Luciano Cognigni, Dr. Maximiliano de Abreu, Dra. Virgina De La Fuente, Dra. Mariela De Santos, Dr. Heraldo D´Imperio, Dr. Gabriel Fernández Frisano, Dr. Federico Gicachello, Dr. Gabriel González Villa Monte, Dr. Marcos Granillo, Dr. Diego Grinfeld, Dr. Cristian Guridi, Dr. Agustín Hauqui, Dr. Diego Herrera, Dr. Diego Kyle, Gloria Luna, Dr. Javier Mariani, Dra. Mariana Mascia, Dra. Sabrina Merino, Dr. Martín Ordoñez, Dr. Martín Oscos, Dr. Pablo Pedroni, Dra. Daniela Pérez Casal, Dra. Natalia Riga, Dr. Andrés Rosende, Dr. Mauro Rossi Prat, Dr. Ricardo Sarmiento, Dr. Juan Scaglia, Dr. Alejandro Silberstein, Dr. Raúl Solernó, Dra. Gisella Straitenberger, Dr. Carlos Tajer, Dr. Alfonso Teijo, Dra. Paula Velazco,Dr. Martín Vergara, Dra. Angeles Videla Lynch, Dr. Juan Wolcan, Dr. Juan Bacigalupe.