Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.

Clinical Efficacy of Pre-Hospital Electrocardiogram Transmission in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Rapid reperfusion by primary percutaneous coronary intervention (pPCI) is an established strategy for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Pre-hospital electrocardiogram (PH-ECG) transmission by the emergency medical services (EMS) facilitates timely reperfusion in these patients. However, evidence regarding the clinical benefits of PH-ECG in individual hospitals is limited.This retrospective, observational study investigated the clinical efficacy of PH-ECG in STEMI patients who underwent pPCI. Of a total of 382 consecutive STEMI patients, 237 were enrolled in the study and divided into 2 groups: a PH-ECG group (n = 77) and non-PH-ECG group (n = 160). Door-to-balloon time (D2BT) was significantly shorter in the PH-ECG group (66 [52-80] min), compared to the non-PH-ECG group (70 [57-88] minutes, P = 0.01). The 30-day all-cause mortality rate was 6% in the PH-ECG group, which was significantly lower than that in the non-PH-ECG group (16%) (P = 0.037, hazard ratio [HR]: 0.38, 95% CI: 0.15-0.98). This trend was particularly evident in severely ill patients when stratified by GRACE score.The use of PH-ECG improved the survival rate of STEMI patients undergoing pPCI due to the improved pre-arrival preparation based on the EMS information. Coordination between EMS and PCI-capable institutes is essential for the management of PH-ECG.

The Effectiveness of Mobile Cloud 12-Lead Electrocardiogram Transmission System in Patients with ST-Segment Elevation Myocardial Infarction

Backgroundand Objectives: Delay of reperfusion therapy is related to high mortality in cases of ST-segment elevation myocardial infarction (STEMI). Guidelines emphasize that the first-medical-contact-to-balloon (FMCTB) time should be within 90 min. A mobile cloud-based 12-lead electrocardiogram (MC-ECG) transmission system might be useful in such cases, especially in rural areas. Materials and Methods: From April 2019 to June 2021, both an MC-ECG transmission system and the conventional method in which a physician checks the ECG in a hospital (Conventional) were used for transport by emergency medical services in Shin-Yukuhashi Hospital, Fukuoka, Japan. During this period, 8684 consecutive patients were transported to this hospital. Among them, we investigated 48 STEMI patients. The MC-ECG group (n = 23) and the Conventional group (n = 25) were enrolled. Results: There was no significant difference in FMCTB time between the MC-ECG and Conventional groups (MC-ECG: 72.0 (60.5–107) min vs. Conventional: 80.0 (63.0–92.0) min, p = 0.77). The length of hospital stay in the MC-ECG group was significantly shorter than that in the Conventional group (12.0 (10.0–15.0) days vs. 16.0 (12.0–19.0) days, p = 0.039). The logistic regression model showed that patients’ non-use of MC-ECG was associated with a risk of more than 15-day length of hospital stay with an adjusted odd ratio of 0.08 (95% CI: 0.013–0.55, p = 0.0098). Conclusions: Using the MC-ECG, the length of hospital stay in patients with STEMI was significantly reduced.

An exploratory study investigating the barriers, facilitators, and demands affecting caregivers in a telemedicine integrated ambulance-based setting for stroke care

Telemedicine implementation in ambulances can reduce time to treatment for stroke patients, which is important as "time is brain" for these patients. Limited research has explored the demands placed on acute stroke caregivers in a telemedicine-integrated ambulance system. This study investigates the impact of telemedicine on workload, teamwork, workflow, and communication of geographically distributed caregivers delivering stroke care in ambulance-based telemedicine and usability of the system. Simulated stroke sessions were conducted with 27 caregivers, who subsequently completed a survey measuring workload, usability, and teamwork. Follow-up interviews with each caregiver ascertained how telemedicine affected workflow and demands which were analyzed for barriers and facilitators to using telemedicine. Caregivers experienced moderate workload and rated team effectiveness and usability high. Barriers included frustration with equipment and with the training of caregivers increasing demands, the loss of personal connection of the neurologists with the patients, and physical constraints in the ambulance. Facilitators were more common with live visual communication increasing teamwork and efficiency, the ease of access to neurologist, increased flexibility, and high overall satisfaction and usability. Future research should focus on eliminating these barriers and supporting the distributed cognition of caregivers.

Present and Future Status of Cardiovascular Emergency Care System in Urban Areas of Japan - Importance of Prehospital 12-Lead Electrocardiogram

Acute cardiovascular disease, such as acute myocardial infarction and aortic disease, can lead to a serious life-threatening state within minutes to hours, so early accurate diagnosis, and appropriate treatment without delay are essential. To provide high-quality and timely treatment, 24-h availability of medical staff and cardiologists, as well as a cardiac catheterization laboratory are needed. In Japan, the number of patients with acute cardiovascular disease is increasing with the aging population and westernization of lifestyle; however, workstyle reforms for physicians, including a policy to limit overtime work, have been legislated. Under these conditions, it is necessary to centralize hospitals that treat cardiovascular emergency diseases as high-volume centers and build a patient triage system for allocating patients before hospital arrival. The prehospital 12-lead electrocardiogram (ECG) plays a central role in prehospital diagnosis and triage, and its importance will increase in future. We discuss the current and future state of the cardiovascular emergency medical care system utilizing prehospital 12-lead ECG in urban areas of Japan.

Prehospital tele-electrocardiographic triage improves the management of acute coronary syndrome in rural populations: A systematic review and meta-analysis

INTRODUCTION

Acute coronary syndrome (ACS) patients residing in rural areas are predisposed to higher risk of poor outcomes due to substantial delays in disease management, emphasising the importance of emerging telecardiology technologies in delivering emergency services in such settings. This meta-analysis aimed to investigate the impacts of prehospital telecardiology strategies on the clinical outcomes of rural ACS patients.

METHODS

A literature search was performed of articles published up to April 2020 through six databases. Included studies were assessed for bias risk using the ROBINS-I tool, and a random-effects model was utilised to estimate effect sizes. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

Twelve studies with a total of 3989 patients were included in this review. Prehospital telecardiology in the form of tele-electrocardiography (tele-ECG) enabled prompt diagnosis and triage, resulting in a decreased door-to-balloon (DTB) time (mean difference = -25.53 minutes, 95% confidence interval (CI) -36.08 to -14.97 minutes; I² = 98%), as well as lower in-hospital mortality (odds ratio (OR) = 0.57, 95% CI 0.36-0.92) and long-term mortality (OR = 0.52, 95% CI 0.39-0.69) rates, both with negligible heterogeneity (I² = 0%). GRADE assessment yielded very low to moderate certainty of evidence.Conclusion Prehospital tele-ECG appeared to be an effective and worthwhile approach in the management of rural ACS patients, as shown by moderate quality evidence on lower long-term mortality. Given the uncertainties of the evidence quality on DTB time and in-hospital mortality, future studies with a higher quality of evidence are required to confirm our findings.

Comparison of in-hospital death following ST-elevation myocardial infarction between secondary emergency and tertiary emergency

In most areas in Japan, patients with ST-elevation myocardial infarction (STEMI) would be transferred to the secondary hospitals or tertiary hospitals according to the judgement of emergency medical service (EMS) staff members. We hypothesized that in-hospital outcomes would be worse in STEMI patients judged as tertiary emergency than in those judged as secondary emergency, which may support the judgement of the current EMS systems. The purpose of this study was to compare in-hospital outcomes of STEMI between patients judged as secondary emergency and those judged as tertiary emergency. We included 238 STEMI patients who were transferred to our institution using EMS hotline, and divided those into the secondary emergency group (n = 106) and the tertiary emergency group (n = 132). The primary endpoint was in-hospital death. The prevalence of shock was significantly higher in the tertiary emergency group than in the secondary emergency group (32.6% vs. 10.4%, p < 0.001). The GRACE score was significantly higher in the tertiary emergency group than the secondary emergency group [146 (118–188) vs. 134 (101–155), p < 0.001]. The incidence of in-hospital death was significantly higher in the tertiary emergency group than in the secondary emergency group (8.0% vs. 2.1%, p = 0.014). The multivariate logistic regression analysis revealed that the tertiary emergency was significantly associated with in-hospital death (OR 3.52, 95% CI 1.24–10.02, p = 0.018) after controlling age and gender. In conclusion, the tertiary emergency was significantly associated with in-hospital death. Our results might validate the judgement of levels of emergency by local EMS staff members.

Impact of Mobile Cloud Electrocardiography System on Door-to-Balloon Time in Patients With Acute Coronary Syndrome in Oita Prefecture

Background: The mobile cloud electrocardiography (C-ECG) system is useful for reducing door-to-balloon (DTB) time in patients with acute coronary syndrome (ACS), but few studies have reported the usefulness of the C-ECG system across a wide provincial prefecture, such as Oita, in Japan. Methods and Results: On 17 April 2017, the C-ECG system was integrated into the Oita remote image transmission system, in 10 ambulances of 10 respective fire departments in Oita Prefecture. During 6 months, 162 ECG indicating suspected ACS were transmitted to 18 hospitals using the C-ECG system. Of 162 patients, 17 who received emergency percutaneous coronary intervention (PCI) were assigned to the cloud group (mean age, 71±11 years). The control group consisted of 29 consecutive ACS patients who were transported to Oita University Hospital without using the C-ECG system (mean age, 66±12 years). Another 40 consecutive patients were diagnosed with ACS before transportation to Oita University Hospital, and were assigned to the diagnosed group (mean age, 70±14 years). DTB time (70±26 min vs. 96±24 min, P<0.005) and door-to-catheterization laboratory time (33±20 min vs. 53±22 min, P<0.0001) were shorter in the cloud group than in the control group, respectively. Conclusions: C-ECG system integration in Oita Prefecture was useful to appropriately transfer ACS patients to hospital and to facilitate earlier PCI than in the conventional diagnostic system.

The use of telemedicine for delivering healthcare in Japan: Systematic review of literature published in Japanese and English languages

Background In common with other countries, Japan has an ageing population and geographical impediments to healthcare access. The role of telemedicine within the Japanese health system may be of wide interest, yet it has not been comprehensively explored and documented. Thus, the aim of this study was to systematically review the Japanese and English language literature relating to the clinical use of telemedicine in Japan. Methods For studies published in Japanese, we searched Ichushi and CiNii. For English language publications, we searched Cochrane Library, PubMed, Embase, and Web of Science. All peer-reviewed articles describing the clinical use of telemedicine and published between 2007 and 2016 were included. Data on clinical area, study type, technology used, and type of communication were extracted. Studies were categorised by prevention, screening, diagnosis, surveillance, and treatment. Results The search yielded 1476 records; 26 Japanese language and 15 English language articles were selected for review. A wide range of clinical areas were represented; however, home care and life-style related studies were dominant. More than 50% of studies were related to prevention and early diagnosis. The majority of Japanese studies involved doctor-to-doctor consultation. Smartphones and remote monitoring systems were the main types of technology used. Conclusions Most studies of telemedicine in Japan are published in the Japanese language and are thus relatively inaccessible to the rest of the world; for the first time, this study has provided an overview of the clinical use of telemedicine in Japan. The clinically related papers reflect the Japanese cultural focus on disease prevention.

Reduction in Door-to-Balloon Time with Training for Effective and Efficient Action in Medical Service-Better Process (TEAMS-BP) at a Community Hospital in Japan

ST-elevation myocardial infarction (STEMI) is a fatal condition. Prompt primary percutaneous coronary intervention is associated with lower mortality. However, community hospitals in Japan lack human and medical resources, and implementation of the same strategies as those used in the USA, such as an on-call cardiologist at the hospital, to achieve a door-to-balloon time of ≤ 90 min appears particularly challenging. Therefore, we used Training for Effective and Efficient Action in Medical Service-Better Process (TEAMS-BP) to develop a new process and assessed its effectiveness in reducing door-to-balloon time. TEAMS-BP can optimize the process by making the best use of available materials, machines, facilities and manpower. All processes conducted by physicians, nurses, electrocardiogram technicians, radiological technologists, and clerical staff in the emergency room were reviewed, documented, and standardized using the four steps of TEAMS-BP. The following processes were implemented: setting time goals, calling an electrocardiogram technician beforehand, minimizing tasks before calling a cardiologist, confirming the checklist, and providing data feedback. Forty-four STEMI patients who were treated after TEAMS-BP implementation were compared with 58 who were treated before implementation. Median door-to-balloon, door-to-electrocardiogram and door-to-laboratory times were significantly reduced after TEAMS-BP implementation, decreasing from 106 to 82 min, 14 to 6 min, and 67 to 45 min, respectively. In conclusion, implementation of TEAMS-BP improved the door-to-balloon time of STEMI cases without additional resources or costs incurred by the hospital. TEAMS-BP can be implemented by any hospital wishing to develop a new process that accommodates local working conditions.

Acute Pericarditis Following Acute Pulmonary Thromboembolism

We describe the case of a 45-year-old Japanese man who developed acute pericarditis following an acute pulmonary thromboembolism. He had developed shortness of breath 7 days prior to hospitalization and was admitted with severe dyspnea. Echocardiography and laboratory results were compatible with acute pulmonary thromboembolism, which was confirmed by contrast-enhanced chest computed tomography. On the third hospital day, he experienced chest pain exacerbated by inspiration. On the fourth hospital day, his body temperature increased to 39°C and echocardiography revealed circumferential pericardial effusion. A diagnosis of acute pericarditis was made and the patient was treated with colchicine and aspirin. On the fifth hospital day, his symptoms largely subsided. Auscultation revealed pericardial friction rub. Electrocardiography demonstrated diffuse ST-segment elevations. Twenty-four days later, computed tomography revealed the disappearance of both the pericardial effusion and pulmonary arterial emboli. This case was thought to be one of acute pericarditis following acute pulmonary thromboembolism.

Determinants of short and long door-to-balloon time in current primary percutaneous coronary interventions

Primary percutaneous coronary interventions (PCI) have been developed to improve clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). In primary PCI, the door-to-balloon time (DTBT) is closely associated with mortality and morbidity. The purpose of this study was to find determinants of short and long DTBT. From our hospital record, we included 214 STEMI patients, and divided into the short DTBT group (DTBT < 60 min, n = 60), the intermediate DTBT group (60 min ≤ DTBT ≤ 120 min, n = 121) and the long DTBT group (DTBT > 120 min, n = 33). In-hospital mortality was highest in the long DTBT group (24.2%), followed by the intermediate DTBT group (5.8%), and lowest in the short DTBT group (0%) (< 0.001). Transfers from local clinics or hospitals (OR 3.43, 95% CI 1.72-6.83, P < 0.001) were significantly associated with short DTBT, whereas Killip class 3 or 4 (vs. Killip class 1 or 2: OR 0.20, 95% CI 0.06-0.64, P = 0.007) was inversely associated with short DTBT in multivariate analysis. In conclusion, transfer from local clinics/hospitals was associated with short DTBT. Our results may suggest the current limitation of ambulance system, which does not include pre-hospital ECG system, in Japan. The development of pre-hospital ECG system would be needed for better management in STEMI.

A Systematic Review of the Implementation Challenges of Telemedicine Systems in Ambulances

BACKGROUND

Telemedicine systems are gaining attention nationwide as a means for providing care in remote areas and allowing a small number of providers to impact a large geographic region. We systematically reviewed the literature to identify the efficacy and implementation challenges of telemedicine systems in ambulances.

METHODS

A search for published studies on Web of Science and PubMed was completed. Studies were selected if they included at least a pilot study and they focused on feasibility or implementation of telemedicine systems in ambulances.

RESULTS

A total of 864 articles were used for title and abstract screening. Full text screening was completed for 102 articles, with 23 being selected for final review. Sixty-one percent of the studies included in the review focused on general emergency care, while 26% focused on stroke care and 13% focused on myocardial infarction care. The reviewed studies found that telemedicine is feasible and effective in decreasing treatment times, report a high diagnosis accuracy rate, show higher rates of positive task completion than in regular ambulances, and demonstrate that stroke evaluation is completed with comparable accuracy to the standard way of delivering care.

CONCLUSIONS

Although this review identified life-saving benefits of telemedicine, it also showed the paucity of the scientifically sound research in its implementation, prompting further studies. Further research is needed to analyze the capabilities and challenges involved in implementing telemedicine in ambulances, especially studies focusing on human-system integration and human factors' considerations in the implementation of telemedicine systems in ambulances, the development of advanced Internet connectivity paradigms, additional applications for triaging, and the implications of ambulance location.

Determinants of In-Hospital Death in Acute Myocardial Infarction With Triple Vessel Disease

Compared to acute myocardial infarction (AMI) with single vessel disease (SVD) or double vessel disease (DVD), AMI with triple vessel disease (TVD) is associated with higher mortality. The aim of this study was to identify the determinants of in-hospital death in AMI with TVD. We identified AMI patients with TVD in our tertiary medical center between January 2009 and December 2014. Baseline patient characteristics including laboratory data, echocardiograms, and coronary angiograms were collected from our hospital records. We divided our study population into a survivor group and non-survivor group. Multivariate stepwise logistic regression analysis was performed to identify the determinants of in-hospital death. A total of 138 AMI patients with TVD were identified and included as the final study population. Fifteen patients died during the hospitalization (mortality rate, 10.9%). Mean systolic blood pressure (134 ± 27 mmHg) was significantly greater in the survivor group compared with the non-survivor group (114 ± 31 mmHg) (P = 0.02). The prevalence of shock on admission was significantly less in the survivor group (15.4%) than in the non-survivor group (66.7%) (P < 0.001). Multivariate stepwise logistic regression analysis revealed that shock status on admission (OR 11.50, 95% CI 3.21-41.14, P < 0.001), the left anterior descending artery (LAD) as the infarct related artery (IRA) (OR 3.83, 95% CI 1.04-14.09, P = 0.04), and serum albumin on admission (OR 0.26, 95% CI 0.08-0.84, P = 0.02) were significantly associated with in-hospital death. In conclusion, shock status on admission, the LAD as the IRA, and a low serum albumin level were the determinants of in-hospital death in AMI patients with TVD.

A systematic review of the methodologies used to evaluate telemedicine service initiatives in hospital facilities

BACKGROUND

The adoption of telemedicine into mainstream health services has been slower than expected. Many telemedicine projects tend not to progress beyond the trial phase; there are a large number of pilot or project publications and fewer 'service' publications. This issue has been noted since 1999 and continues to be acknowledged in the literature. While overall telemedicine uptake has been slow, some services have been successful. The reporting and evaluation of these successful services may help to improve future uptake and sustainability. The aim of this literature review was to identify peer-reviewed publications of deployed telemedicine services in hospital facilities; and to report, and appraise, the methodology used to evaluate these services.

METHODS

Computerised literature searches of bibliographic databases were performed using the MeSH terms for "Telemedicine" and "Hospital Services" or "Hospital", for papers published up to May 2016.

RESULTS

A total of 164 papers were identified, representing 137 telemedicine services. The majority of reported telemedicine services were based in the United States of America (n=61, 44.5%). Almost two thirds of the services (n=86, 62.7%) were delivered by real time telemedicine. Of the reviewed studies, almost half (n=81, 49.3%) assessed their services from three different evaluation perspectives: clinical outcomes, economics and satisfaction. While the remaining half (n=83, 50.6%) described their service and its activities without reporting any evaluation measures. Only 30 (18.2%) studies indicated a two-step implementation and evaluation process. There was limited information in all reported studies regarding description of a structured planning strategy.

CONCLUSION

Our systematic review identified only 137 telemedicine services. This suggests either telemedicine service implementation is still not a part of mainstream clinical services, or it is not being reported in the peer-reviewed literature. The depth and the quality of information were variable across studies, reducing the generalisability. The reporting of service implementation and planning strategies should be encouraged. Given the fast paced technology driven environment of telemedicine, this may enable others to learn and understand how to implement sustainable services. The key component of planning was underreported in these studies. Studies applying and reporting more rigorous methodology would contribute greatly to the evidence for telemedicine.