[Optimizing systems of care for patients with acute myocardial infarction. STEMI networks, telemetry ECG, and standardized quality improvement with systematic data feedback]

[Present and future relevance of telemedicine in cardiac arrhythmia emergencies]

BACKGROUND

The use of remote monitoring has increased due to recently published randomised studies. However, its benefit during acute rhythm disorders still remains controversial.

OBJECTIVES

The current review describes the current status and highlights possible application of telemedicine during acute rhythm disorders.

MATERIALS AND METHODS

The prerequisites, structural properties of the sender/patient and the receiver of the data/physician are examined and the results of the current literature are presented.

RESULTS

Telemedicine during emergency rhythm disorders are normally reserved for specific scenarios. The lack of 24/7 staff of the receiver/hospital represents the main barrier.

CONCLUSIONS

Remote medicine in the current form is not yet ready to be implemented for acute rhythm disorders. Expansion of currently existing chest pain units (CPUs) might enable this 24/7 service in the near future.

[Heart failure networks and centers : What does everyday life look like?]

The German Cardiac Society (DGK) and the German Society for Thoracic and Cardiovascular Surgery (DGTHG) jointly advocated the initiation and certification of heart failure (HF) networks in a position statement in 2016. In these networks, supraregional HF centers cooperate with specialized regional HF clinics and registered cardiologists to improve intersectoral treatment of patients with HF. So far predominantly supraregional HF centers have achieved certification but more recently regional clinics as well as registered cardiologists have applied for certification, now enabling the comprehensive establishment of HF networks. In this article the background, the current situation and the future perspectives of HF networks are assessed and approaches for better networking are discussed.

A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction

Patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the highest mortality rates recorded in critical care. Mortality rate in this setting is reported around 45-50% even in the most experienced and well-equipped medical centers. The continuous development of ST-segment elevation acute myocardial infarction (STEMI) networks has led not only to a dramatic decrease in STEMI-related mortality, but also to an increase in the frequency of severely complicated cases who survive to be transferred to tertiary centers for life-saving treatments. The reduced effectiveness of vasoactive drugs on a severely altered hemodynamic status led to the development of new devices dedicated to advanced cardiac support. What’s more, efforts are being made to reduce time from first medical contact to initiation of mechanical support in this particular clinical context. This review aims to summarize the most recent advances in mechanical support devices, in the setting of CS-complicated AMI. At the same time, the review presents several modern concepts in the organization of complex CS centers. These specialized hubs could improve survival in this critical condition.

Review. Regional Networks in Acute Cardiac Care

In acute cardiac care, the timely initiation of life-saving measures proved to be life-saving and requires many organizational and logistic measures. One of such measures is represented by the development and implementation of a regional network dedicated for the treatment of major cardiovascular emergencies, a strategy that proved to significantly reduce mortality rates on short and long term. This review aims to describe the current status in the development of regional networks in three of the main cardiovascular emergencies: acute myocardial infarction, out-of-hospital cardiac arrest, and acute stroke. The concepts demonstrating the utility of such networks, together with their results in reducing cardiac events, are presented in this paper.

[Telemedical prenotification in acute stroke treatment : Experiences from the Stroke Angel initiative from 2004 until the present]

OBJECTIVE

The Stroke Angel initiative investigates the implementation of telemedicine for improvement of preclinical communication between emergency medical services (EMS) and stroke units in cases of acute stroke.

MATERIAL AND METHODS

Stroke Angel is a technical system for the telemedical prenotification of patients in cases of suspected stroke at a stroke unit by the EMS. Within the framework of an observational study, the team has been investigating the effects of the system on door-to-computed tomography (CT) and door-to-needle times as well as the lysis rate in the neighboring regions of Rhön-Grabfeld and Bad Kissingen since 2005.

RESULTS

The system supports the acute treatment of neurological emergencies and functions as a catalyst for the interlinking of medical institutions in the region as well as for communication between emergency physicians/EMS and hospital physicians. The use of a computer-based data collection enables a continuous improvement process leading to an acceleration of internal clinical procedures and an increase of the lysis rate with the mortality rate staying constant.

CONCLUSION

Telemedicine is applicable in the preclinical care of acute stroke and, thanks to the computer-based data collection, leads to an increase in process transparency, which helps to improve the internal clinical processes in and around a stroke unit.

Factors that influence the acceptance of telemetry by emergency medical technicians in ambulances: an application of the extended technology acceptance model

OBJECTIVE

The aim of the study was to verify the effects of patient factors perceived by emergency medical technicians (EMTs) as well as their social and organizational factors on prehospital telemetry use intention based on the technology use intention and elaboration likelihood models.

MATERIALS AND METHODS

This is a retrospective empirical study. Questionnaires were developed on the basis of clinical factors of 72,907 patients assessed by prehospital telemetry from January 1, 2009 to April 30, 2012 by reviewing their prehospital medical care records and in-hospital medical records. Questionnaires regarding the social and organizational factors of EMTs were created on the basis of a literature review. To verify which factors affect the utilization of telemetry, we developed a partial least-squares route model on the basis of each characteristic. In total, 136 EMTs who had experience in using prehospital telemetry were surveyed from April 1 to April 7, 2013. Reliability, validity, hypotheses, and the model goodness of fit of the study tools were tested.

RESULTS

The clinical factors of the patients (path coefficient=-0.12; t=2.38), subjective norm (path coefficient=0.18; t=2.63), and job fit (path coefficient=0.45; t=5.29) positively affected the perceived usefulness (p<0.010). Meanwhile, the clinical factors of the patients (path coefficients=-0.19; t=4.46), subjective norm (path coefficient=0.08; t=1.97), loyalty incentives (path coefficient=-0.17; t=3.83), job fit (path coefficient=-0.32; t=7.06), organizational facilitations (path coefficient=0.08; t=1.99), and technical factors (i.e., usefulness and ease of use) positively affected attitudes (path coefficient=0.10, 0.58; t=2.62, 5.81; p<0.010). Attitudes and perceived usefulness significantly positively affected use intention.

CONCLUSIONS

Factors that influence the use of telemetry by EMTs in ambulances included patients' clinical factors, as well as complex organizational and environmental factors surrounding the EMTs' occupational environments. This suggests that the rapid use intention and dissemination of such systems require EMTs to be supported at both the technical and organizational levels.

[The White Paper on treating medical emergencies preclinically and at hospital : how can it be implemented?]

Up-to-date management of medical emergencies implies primarily that definitive diagnoses and treatment are performed in a timely manner. These claims have been reconfirmed in 2007 by the leading German language medical associations in their "White Paper on Emergency Treatment". To actually realize the demands described in this paper a timely, transsectoral and close collaboration of all involved organizations is mandatory. To illustrate this race against cell death the phrase relay of survival is proposed and launched to replace the hitherto used but rigid concept of chain of survival. The tasks of each member of this relay of survival are critically scrutinized one after the other from a patient perspective. The paper presents tangible recommendations for improving the respective individual performance as well as, in particular, the cooperation and coordination between the team members which is comparable to handing over the baton in a relay race.

Factors affecting the use of a realtime telemetry system in emergency medical services

We investigated the factors that affected the use of a realtime telemetry system (RTS) in emergency ambulances. During the study, a total of 7144 patients were transported to a hospital in the city of Wonju via ambulance. In 466 of these cases (7%), the Emergency Medical Technician (EMT) used the RTS. Based on the Elaboration Likelihood Model, we extracted variables from the run records, such as the qualifications of the EMT, level of the patient's consciousness and the transport time. The results indicated that EMTs with higher levels of expertise were more likely to use the RTS when the level of patient consciousness was low, regardless of transport time. Conversely, EMTs with low levels of expertise were more likely to use the RTS when the transport time from scene to hospital was long and were less likely to use the RTS when the transport time was short. There appear to be several ways of improving RTS usage in the pre-hospital situation.

The quality of emergency medical care in baden-württemberg (Germany): four years in focus

BACKGROUND

In 2004, the German federal state of Baden-Württemberg implemented a quality management system for pre-hospital emergency care. Since then, there has been a semi-annual assessment of the frequency of different types of emergency medical interventions and the quality of care.

METHODS

The frequencies of different types of intervention were determined and reported both in absolute numbers and as incidence figures, i.e., interventions per 1000 inhabitants per year. The quality of care was rated with the Mainz Emergency Evaluation Score (MEES), and analyses of resuscitation outcomes and guideline implementation were performed.

RESULTS

From 2004 to 2008, there were a total of 524,833 pre-hospital emergency medical interventions in Baden-Württemberg. The annual incidence of emergency interventions rose by 22% over this period (from 16.2 to 19.9 interventions per 1000 inhabitants per year), and the percentage of patients who were severely ill or severely injured rose as well, from 47.3% to 51.1%. The percentage of patients over age 75 rose from 29.1% to 31.3%. 11,858 patients with myocardial infarction (MI) were treated in 2008; the incidence of treatment for MI rose by 60% from 2004 to 2008, from 0.907 to 1.448 interventions per 1000 inhabitants per year. A major improvement in the diagnostic evaluation of MI came about through the purchase of more 12-channel ECG machines. In 2008, the emergency medical teams succeeded in improving the patient's condition in 69.07% of all cases (77.9% for MI, 63.2% for stroke, 74.4% for multiple trauma). 21 patients per 100,000 inhabitants per year arrived in the hospital alive after out-of-hospital cardiac arrest and pre-hospital resuscitation.

CONCLUSIONS

Even in the face of increasing utilization, the quality of emergency medical care in Baden-Württemberg has remained high. Since a quality management system was introduced in 2004, the physicians in charge of emergency medical teams have had access to the data that they need in order to evaluate and further develop the services that they provide.

[Acute myocardial infarction: acute coronary intervention at any hospital versus acute coronary intervention at specialized centers only]

The acute coronary syndromes (ACS) are currently divided into those with ST elevation (STE-ACS = ST elevation myocardial infarction [STEMI]) and those without ST elevation (NSTE-ACS). The latter are further divided into NSTE-ACS with risk factors and NSTE-ACS without risk factors. For NSTE-ACS patients with risk factors an invasive strategy within 72 h after presentation is recommended, whereas NSTE-ACS patients without risk factors can be treated conservatively, without a routine invasive diagnosis. In patients with STE-ACS, primary angioplasty is the reperfusion therapy of choice. These recommendations concerning the invasive strategies are valid only under three conditions: (1) primary angioplasty has to be performed within 2 h after diagnosis of an STE-ACS; (2) door-to-balloon times for STE-ACS have to be < 60 min; (3) the invasive procedures have to be performed by experienced investigators at hospitals with a sufficient annual PCI (percutaneous coronary intervention) volume. The last point is based on studies which showed a volume-outcome relationship for PCIs in ACS patients and hospital mortality. In Germany, a nationwide supply with such an invasive strategy for ACS patients is currently possible, even within the recommended time frames. Therefore, local networks have to be established to achieve this goal. However, at least in regions with a high density of invasive centers, such networks should take the investigators' experience and the annual interventional volumes of the participating hospitals into account.