Impact of Chest Pain Protocol with Access to Telemedicine on Implementation of Pharmacoinvasive Strategy in a Private Hospital Network

Introduction

In recent years, improvement and cost reduction in telecommunication services have led to the worldwide expansion of the use of telemedicine. ^1,2 This tool has the potential to efficiently expand medical care to patients. ^3,4 At present there are several applications for telemedicine around the world, and its use is permitted for clinical discussions between medical professionals, although not directly authorized for virtual consultations between doctors and patients, in Brazil. By allowing rapid interaction between physicians of different specialties, telemedicine can reduce the time required for diagnosis/treatment and reduce costs related to any unnecessary procedure. ^{5 –8} Recent government programs have increased the use of telemedicine in public services in Brazil, but financial issues hinder the wider use of this tool in the public health service. ⁹

Although some private services have started using telemedicine, there are still many limitations in communication between central hospitals and peripheral health services, particularly in a country with continental dimensions such as Brazil. Limited communication is a common problem regarding the transportation of patients to referral centers. The distance to be traveled and the absence of an effective flow in transporting patients in emergency situations require prompt and appropriate solutions. The existence of a direct connection with specialists enables quick decisions in the care of critically ill patients, even in distant centers.

In order to provide access to healthcare quickly and evenly, a telemedicine program was created to interconnect various emergency units of a private health care network that includes five cities by professionals available 24 h/day. This system allows direct visual communication between peripheral centers and institutions for support diagnosis, treatment guidance, and educational intervention. The aim of this study is to compare the use of the pharmacoinvasive strategy and mortality in patients with ST elevation myocardial infarction (STEMI) transferred pre– and post–chest pain protocol with access to telemedicine (CPPT) in a private hospital network.

Materials and Methods

This is an observational study of all calls made consecutively in the first 2 years of the CPPT. In 2012, emergency physicians and nurses were trained in the management of patients with acute onset of symptoms suggestive of acute coronary syndrome. The institutional chest protocol included practical routine care of patients with acute chest pain in accordance with the recommendations of the main guidelines in cardiology. The medical and nursing care was organized by routes to be followed upon clinical presentation of a patient with acute coronary syndrome to facilitate following of the clinical procedures; the routes served as a guide to reduce morbidity and mortality, and the hospital structure was optimized to achieve the goals. After discharge, the patient received instructions for medication use and consultation with his or her doctor. We established measurable goals involving the best care practices, minimizing the time to perform clinical diagnostic and therapeutic procedures, and guidance for the use of resources network (telemedicine) focusing on reperfusion therapy (pharmacoinvasive strategy).

In the same year (2012), wide access to telemedicine was implemented in 22 emergency departments of five cities in three states of Brazil, headed by a reference hospital in cardiology (RHC) available 24 h/day, 7 days/week. The telemedicine system was used for clinical discussions and transfers to the RHC in case of need for diagnosis and/or further treatment to improve a patient's clinical health status. Consultations with cardiologists were initiated through a system beep triggered via the Internet by the health service needs of the query. A cardiologist from the RHC had a pager that was activated, and once the beeper received a message, the cardiologist had a maximum of 5 min to respond. The discussion was based on clinical history data, graphical methods (electrocardigram), and laboratory tests shared by the telemedicine system.

We used a teleconferencing device that allows transmission in high definition (Polycom^® [San Jose, CA] HDX 6000 HD camera with Eagle Eye), which facilitates the discussion of clinical cases and evaluation of the electrocardiogram with zoom feature (through the projector's Elmo^® [Westminster, CA] document camera). All services were performed by a high-speed connection with at least 4 megabytes dedicated for each link (>100 megabytes for the network). In the case of radiological examinations (e.g., computerized tomography), there is a system that allows viewing of the electronic Internet image, which can be used by radiologists to view the reports from remote locations.

All specialists were at a center that specialized in cardiology, allowing transfer to their hospital in situations that required more complex diagnostic or therapeutic resources.

The data related to each consultation via telemedicine were collected using a standardized form filled out by both doctors involved (specialist and nonspecialist). Subsequently, these data were entered into a central database managed by the Coordinator of Telemedicine. Patient identification, age, sex, diagnosis, and other variables were included, besides the identification of health professionals and services related to contact. In cases where the information was inconsistent between health professionals, these data were reviewed by the team involved before confirmation in the database. The information of all transferred cases to the RHC was included in the hospital's internal database to compare the groups of patients observed in 2011 (pre-CPPT) and 2013–2014 (post-CPPT).

Results

There was a progressive increase in the number of total calls over this 2 year-period: from 131 calls in 2011 to 1,683 in 2013–2014. The number of unsuccessful calls to the telemedicine center was less than 1% of the records, with almost all of them due to problems with the Internet and not related to the device or to the consultant physician.

We included 376 patients (113 pre-CPPT and 263 post-CPPT) with STEMI (Table 1). All patients admitted in the RHC were transferred from the 22 emergency departments. Comparing pre-CPPT and post-CPPT, we did not find differences in mean age (59.6 ± 13 versus 58.7 ± 11 years; p = 0.49), gender (males, 70% versus 74.9%; p = 0.40), hypertension (69% versus 63.1%; p = 0.29), dyslipidemia (46% versus 43%; p = 0.65), diabetes (27.4% versus 29.3%; p = 0.80), smoking (31% versus 36.5%; p = 0.34), previous myocardial infarction (7.1% versus 5.7%; p = 0.74), previous heart failure (6.2% versus 5.7%; p = 0.78), or Killip classification of ≥2 (22.1% versus 41%; p = 0.16). However, when we used the CPPT, we found a greater use of pharmacoinvasive strategy (55.8% versus 38%; p = 0.002) and a trend toward lower in-hospital mortality (3% versus 8%; p = 0.06) (Table 2).

Discussion

The present investigation has important findings regarding the periods pre- and post-CPPT: (a) we found a growing demand for discussions in telemedicine, and (b) there was a greater use of pharmacoinvasive strategy and trend toward lower mortality during the treatment of patients with STEMI. The greater advantage of a telemedicine-associated chest pain protocol is the direct contact with a specialist cardiologist to trigger the initiation of fibrinolysis (pharmacoinvasive therapy) or activating the catheterization laboratory in cases of STEMI. Moreover, with the cardiologist's expertise, it may also be possible to reduce the number of incorrect diagnoses. ¹⁰

The implementation of the CPPT was in accordance with guidelines ^11,12 for the treatment of STEMI, with potential reduction of transport costs. We have included more patients with acute coronary syndrome than in other studies. ^10,13 Several studies ^{14 –16} have demonstrated reduction in delay in diagnosis of STEMI using 12-lead electrocardiogram transmission, allowing administration of fibrinolytics ¹⁷ and rerouting patients to hospitals with a capability to perform percutaneous coronary intervention. ¹⁸

In the context of challenges in healthcare, accessible telemedicine is a promising tool. The results of the first 2 years of innovative routine use in a large private health system showed that there was a progressive increase in number of patients included in the CPPT (113 versus 263). We included more patients with STEMI followed via telemedicine than other studies ^16,18 and observed increased use of the pharmacoinvasive strategy. Patients eligible for percutaneous coronary intervention were potential candidates for telemedical monitoring. In our study, following the recommendations of our protocol and similar to previous reports, ¹⁹ the use of telemedicine was associated with a trend toward lower in-hospital mortality when comparing the 2011 (pre-CPPT) and 2013–2014 (post-CPPT) periods (Table 2). The mortality rate was 8% before the protocol implementation and fell to 3% (p = 0.06) after the use of CPPT. This suggests that an educational program with practical training is of great importance to further assist emergency professionals in the early identification and appropriate use of telemedicine in cases of suspected myocardial infarction with STEMI. This integration of educational intervention and consultation via telemedicine should lead to better outcomes in the care of these patients and would allow overcoming the gap between evidence-based recommendations and actual clinical practice.

The present study has some limitations that should be addressed. Although rare (<1%), we had problems with the transmission of images via telemedicine. To solve these problems there was a possibility that we could activate our information technology team to present such situations. Another limitation is that our study was not randomized, and the cases were evaluated retrospectively, allowing no guarantee that the cause–effect of major outcomes after implementation of CPPT would be better evaluated using a longitudinal study.

Conclusions

The implementation of a chest pain protocol with access to telemedicine was associated with a significant increase in the use of pharmacoinvasive strategy in patients with STEMI and a trend toward reduced in-hospital mortality in a private hospital network.