Artificial intelligence-assisted remote detection of ST-elevation myocardial infarction using a mini-12-lead electrocardiogram device in prehospital ambulance care

Applications and Performance of Machine Learning Algorithms in Emergency Medical Services: A Scoping Review

OBJECTIVE

The aim of this study was to summarize the literature on the applications of machine learning (ML) and their performance in Emergency Medical Services (EMS).

METHODS

Four relevant electronic databases were searched (from inception through January 2024) for all original studies that employed EMS-guided ML algorithms to enhance the clinical and operational performance of EMS. Two reviewers screened the retrieved studies and extracted relevant data from the included studies. The characteristics of included studies, employed ML algorithms, and their performance were quantitively described across primary domains and subdomains.

RESULTS

This review included a total of 164 studies published from 2005 through 2024. Of those, 125 were clinical domain focused and 39 were operational. The characteristics of ML algorithms such as sample size, number and type of input features, and performance varied between and within domains and subdomains of applications. Clinical applications of ML algorithms involved triage or diagnosis classification (n = 62), treatment prediction (n = 12), or clinical outcome prediction (n = 50), mainly for out-of-hospital cardiac arrest/OHCA (n = 62), cardiovascular diseases/CVDs (n = 19), and trauma (n = 24). The performance of these ML algorithms varied, with a median area under the receiver operating characteristic curve (AUC) of 85.6%, accuracy of 88.1%, sensitivity of 86.05%, and specificity of 86.5%. Within the operational studies, the operational task of most ML algorithms was ambulance allocation (n = 21), followed by ambulance detection (n = 5), ambulance deployment (n = 5), route optimization (n = 5), and quality assurance (n = 3). The performance of all operational ML algorithms varied and had a median AUC of 96.1%, accuracy of 90.0%, sensitivity of 94.4%, and specificity of 87.7%. Generally, neural network and ensemble algorithms, to some degree, out-performed other ML algorithms.

CONCLUSION

Triaging and managing different prehospital medical conditions and augmenting ambulance performance can be improved by ML algorithms. Future reports should focus on a specific clinical condition or operational task to improve the precision of the performance metrics of ML models.

Designing Chinese hospital emergency departments to leverage artificial intelligence-a systematic literature review on the challenges and opportunities

Artificial intelligence (AI) has witnessed rapid advances in the healthcare domain in recent years, especially in the emergency field, where AI is likely to radically reshape medical service delivery. Although AI has substantial potential to enhance diagnostic accuracy and operational efficiency in hospitals, research on its applications in Emergency Department building design remains relatively scarce. Therefore, this study aims to investigate Emergency Department facility design by identifying the challenges and opportunities of using AI. Two systematic literature reviews are combined, one in AI and the other in sensors, to explore their potential application to support decision-making, resource optimisation and patient monitoring. These reviews have then informed a discussion on integrating AI sensors in contemporary Emergency Department designs for use in China to support the evidence base on resuscitation units, emergency operating rooms and Emergency Department Intensive Care Unit (ED-ICU) design. We hope to inform the strategic implementation of AI sensors and how they might transform Emergency Department design to support medical staff and enhance the patient experience.

An Artificial Intelligence Analysis of Electrocardiograms for the Clinical Diagnosis of Cardiovascular Diseases: A Narrative Review

Artificial intelligence (AI) applied to cardiovascular disease (CVD) is enjoying great success in the field of scientific research. Electrocardiograms (ECGs) are the cornerstone form of examination in cardiology and are the most widely used diagnostic tool because they are widely available, inexpensive, and fast. Applications of AI to ECGs, especially deep learning (DL) methods using convolutional neural networks (CNNs), have been developed in many fields of cardiology in recent years. Deep learning methods provide valuable support for rapid ECG interpretation, demonstrating a diagnostic capability overlapping with specialists in the diagnosis of CVD by a classical analysis of macroscopic changes in the ECG trace. Through photoplethysmography, wearable devices can obtain single-derivative ECGs for the recognition of AI-diagnosed arrhythmias. In addition, CNNs have been developed that recognize no macroscopic electrocardiographic changes and can predict, from a 12-lead ECG, atrial fibrillation, even from sinus rhythm; left and right ventricular function; hypertrophic cardiomyopathy; acute coronary syndromes; or aortic stenosis. The fields of application are many, but numerous are the limitations, mainly associated with the reliability of the acquired data, an inability to verify black box processes, and medico-legal and ethical problems. The challenge of modern medicine is to recognize the limitations of AI and overcome them.

A Novel Algorithm for Improving the Prehospital Diagnostic Accuracy of ST-Segment Elevation Myocardial Infarction

INTRODUCTION

Early detection of ST-segment elevation myocardial infarction (STEMI) on the prehospital electrocardiogram (ECG) improves patient outcomes. Current software algorithms optimize sensitivity but have a high false-positive rate. The authors propose an algorithm to improve the specificity of STEMI diagnosis in the prehospital setting.

METHODS

A dataset of prehospital ECGs with verified outcomes was used to validate an algorithm to identify true and false-positive software interpretations of STEMI. Four criteria implicated in prior research to differentiate STEMI true positives were applied: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. The test characteristics were calculated and regression analysis was used to examine the association between the number of criteria included and test characteristics.

RESULTS

There were 44,611 cases available. Of these, 1,193 were identified as STEMI by the software interpretation. Applying all four criteria had the highest positive likelihood ratio of 353 (95% CI, 201-595) and specificity of 99.96% (95% CI, 99.93-99.98), but the lowest sensitivity (14%; 95% CI, 11-17) and worst negative likelihood ratio (0.86; 95% CI, 0.84-0.89). There was a strong correlation between increased positive likelihood ratio (r2 = 0.90) and specificity (r2 = 0.85) with increasing number of criteria.

CONCLUSIONS

Prehospital ECGs with a high probability of true STEMI can be accurately identified using these four criteria: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. Applying these criteria to prehospital ECGs with software interpretations of STEMI could decrease false-positive field activations, while also reducing the need to rely on transmission for physician over-read. This can have significant clinical and quality implications for Emergency Medical Services (EMS) systems.

Artificial Intelligence in Optimizing the Functioning of Emergency Departments; a Systematic Review of Current Solutions

Introduction

The burgeoning burden on emergency departments is a global challenge that we have been confronting for many years. Emerging artificial intelligence (AI)-based solutions may constitute a critical component in the optimization of these units. This systematic review was conducted to thoroughly examine and summarize the currently available AI solutions, assess potential benefits from their implementation, and identify anticipated directions of further development in this fascinating and rapidly evolving field.

Methods

This systematic review utilized data compiled from three key scientific databases: PubMed (2045 publications), Scopus (877 publications), and Web of Science (2495 publications). After meticulous removal of duplicates, we conducted a detailed analysis of 2052 articles, including 147 full-text papers. From these, we selected 51 of the most pertinent and representative publications for the review.

Results

Overall the present research indicates that due to high accuracy and sensitivity of machine learning (ML) models it's reasonable to use AI in support of doctors as it can show them the potential diagnosis, which could save time and resources. However, AI-generated diagnoses should be verified by a doctor as AI is not infallible.

Conclusions

Currently available AI algorithms are capable of analysing complex medical data with unprecedented precision and speed. Despite AI's vast potential, it is still a nascent technology that is often perceived as complicated and challenging to implement. We propose that a pivotal point in effectively harnessing this technology is the close collaboration between medical professionals and AI experts. Future research should focus on further refining AI algorithms, performing comprehensive validation, and introducing suitable legal regulations and standard procedures, thereby fully leveraging the potential of AI to enhance the quality and efficiency of healthcare delivery.

Automatic triage of twelve-lead electrocardiograms using deep convolutional neural networks: a first implementation study

Aims

Expert knowledge to correctly interpret electrocardiograms (ECGs) is not always readily available. An artificial intelligence (AI)-based triage algorithm (DELTAnet), able to support physicians in ECG prioritization, could help reduce current logistic burden of overreading ECGs and improve time to treatment for acute and life-threatening disorders. However, the effect of clinical implementation of such AI algorithms is rarely investigated.

Methods and results

Adult patients at non-cardiology departments who underwent ECG testing as a part of routine clinical care were included in this prospective cohort study. DELTAnet was used to classify 12-lead ECGs into one of the following triage classes: normal, abnormal not acute, subacute, and acute. Performance was compared with triage classes based on the final clinical diagnosis. Moreover, the associations between predicted classes and clinical outcomes were investigated. A total of 1061 patients and ECGs were included. Performance was good with a mean concordance statistic of 0.96 (95% confidence interval 0.95-0.97) when comparing DELTAnet with the clinical triage classes. Moreover, zero ECGs that required a change in policy or referral to the cardiologist were missed and there was a limited number of cases predicted as acute that did not require follow-up (2.6%).

Conclusion

This study is the first to prospectively investigate the impact of clinical implementation of an ECG-based AI triage algorithm. It shows that DELTAnet is efficacious and safe to be used in clinical practice for triage of 12-lead ECGs in non-cardiology hospital departments.

Clinical Research in Prehospital Care: Current and Future Challenges

Prehospital care plays a critical role in improving patient outcomes, particularly in cases of time-sensitive emergencies such as trauma, cardiac failure, stroke, bleeding, breathing difficulties, systemic infections, etc. In recent years, there has been a growing interest in clinical research in prehospital care, and several challenges and opportunities have emerged. There is an urgent need to adapt clinical research methodology to a context of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. Among these, this review allows the highlighting of limited resources and infrastructure, ethical and regulatory considerations, time constraints, privacy, safety concerns, data collection and analysis, selection of a homogeneous study group, etc. The analysis of the literature also highlights solutions such as strong collaboration between emergency medical services (EMS) and hospital care, use of (mobile) health technologies and artificial intelligence, use of standardized protocols and guidelines, etc. Overall, the purpose of this narrative review is to examine the current state of clinical research in prehospital care and identify gaps in knowledge, including the challenges and opportunities for future research.

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.

Current and Future Use of Artificial Intelligence in Electrocardiography

Artificial intelligence (AI) is increasingly used in electrocardiography (ECG) to assist in diagnosis, stratification, and management. AI algorithms can help clinicians in the following areas: (1) interpretation and detection of arrhythmias, ST-segment changes, QT prolongation, and other ECG abnormalities; (2) risk prediction integrated with or without clinical variables (to predict arrhythmias, sudden cardiac death, stroke, and other cardiovascular events); (3) monitoring ECG signals from cardiac implantable electronic devices and wearable devices in real time and alerting clinicians or patients when significant changes occur according to timing, duration, and situation; (4) signal processing, improving ECG quality and accuracy by removing noise/artifacts/interference, and extracting features not visible to the human eye (heart rate variability, beat-to-beat intervals, wavelet transforms, sample-level resolution, etc.); (5) therapy guidance, assisting in patient selection, optimizing treatments, improving symptom-to-treatment times, and cost effectiveness (earlier activation of code infarction in patients with ST-segment elevation, predicting the response to antiarrhythmic drugs or cardiac implantable devices therapies, reducing the risk of cardiac toxicity, etc.); (6) facilitating the integration of ECG data with other modalities (imaging, genomics, proteomics, biomarkers, etc.). In the future, AI is expected to play an increasingly important role in ECG diagnosis and management, as more data become available and more sophisticated algorithms are developed.

Artificial intelligence in critical illness and its impact on patient care: a comprehensive review

Artificial intelligence (AI) has great potential to improve the field of critical care and enhance patient outcomes. This paper provides an overview of current and future applications of AI in critical illness and its impact on patient care, including its use in perceiving disease, predicting changes in pathological processes, and assisting in clinical decision-making. To achieve this, it is important to ensure that the reasoning behind AI-generated recommendations is comprehensible and transparent and that AI systems are designed to be reliable and robust in the care of critically ill patients. These challenges must be addressed through research and the development of quality control measures to ensure that AI is used in a safe and effective manner. In conclusion, this paper highlights the numerous opportunities and potential applications of AI in critical care and provides guidance for future research and development in this field. By enabling the perception of disease, predicting changes in pathological processes, and assisting in the resolution of clinical decisions, AI has the potential to revolutionize patient care for critically ill patients and improve the efficiency of health systems.