Prognosis and Final Diagnosis in ACS using Telemedicine for Field Triage

Transkript

1 Prognosis and Final Diagnosis in ACS using Telemedicine for Field Triage Peter Clemmensen MD, PhD, FESC Maria S Ripa, MD Mikkel Schoos, MD Frans Pedersen, MD, PhD Anders Hvelplund, MD, PhD Erik Jørgensen, MD Department of Cardiology The Heart Center Rigshospitalet Copenhagen University Denmark

2 Background Tele-transmission of 12-lead ECG from the ambulance to Rigshospitalet for triage has been implemented in Region Zealand Consequently, STEMI patients are redirected directly to Rigshospitalet for ppci, often without physician escort STEMI patients are at high risk of developing mechanic or arrhythmic complications within the first hours, making safe ambulance transport pivotal

3 Helicopters Geographics of tele-ecg Transmission Capitol Region max 80 km Western Zealand max 105 km Copenhagen max 20 km Southern Zealand max 180 km EMT ambulances MD ambulances

4 Treatment delay ppci Capital Region Referred patients n= DAILY PRACTISE 2007 Capital Region n= 102 Western Zealand n=49 Southern Zealand n= Median delays (minutes)

5 Objectives Characterize patients with acute coronary syndrome living more than 1 hour from a ppci-capable hospital Determine the influence of transport distance on time to reperfusion therapy and outcome in the subgroup of patients diagnosed with STEMI Determine the rate of complications during ambulance transport time in STEMI patients bypassing local hospitals and emergency departments for ppci Determine in-hospital, 30-day and 1-year mortality rates for all subgroups of patients, and compare the frequencies in STEMI patients in the study population versus control group.

6 Methods I Retrospective study Study population: Patients in contact with the Maribo/Vordingborg MD ambulance service from May 2005 through January 2008 (n=4168 total, n=293 of these referred directly for ppci) Control population: Patients in contact with the Copenhagen MD ambulance service from October 2003 through October 2005 (n=565 total, n=168 of these referred directly for ppci, n=146 received an acute intervention)

7 Methods II Use of different databanks. MD Ambulance database: Local database at Nykøbing and Næstved Hospitals. Includes prehospital times, scene of patient pick-up, medicine given during ambulance transport, complications during transport, ambulance diagnosis, and which hospital the patient was admitted to PATS: Clinical database in the Heart Center at Rigshospitalet. Includes detailed information regarding interventions such as KAG and ppci Danish Heart Registry: Danish National Board of Health s National Patient Registry: Includes data on primary ambulance diagnosis, procedures performed in hospital, follow-up data... National person identification registry: Information on mortality.

8 Geographic's of tele-ecg Transmission Northern Zealand max 80 k Western Zealand max 105 km Copenhagen max 22 km Middle Zealand max 50 km Southern Zealand max 180 km EMT ambulances MD ambulances

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10 Complications during long ground transportation in STEMI patients transferred for ppci Serious Complications Death 1 (1,7%) Hypotension 8 (13.6%) Dyspnoea / Pulm Oedema 4 (6.8%) VES 4 (6.8%) VF 11 (18,7%) VT 2 (3,4%) Bradycardia 12 (20.3%) Other Arrythmias 3 (5.1%) Other observations SVT 1 (1,7%) Hypertension 1 (1,7%) Pain 5 (8,5%) Vomiting 6 (10,2%) Diuresis 1 (1,7%) Total 59 (100,0%)

11 Complications during long ground transportation in STEMI patients transferred for ppci (n=293) Complications Death 1 (0.3%) Hypotension 8 (2.7%) Dyspnoea / Pulm Oedema 4 (1.4%) VF 11 (3.7%) VT 2 (0.6%) Bradycardia 12 (4.1%)

12 911 to Door in STEMI - Long Transportation

13 Complications during STEMI transfer 911 to ppci center p value median (92 min) > median (92 min) Minor 80 (43.5%) 72 (39.1%) complication Complication 12 (6.5%) 20 (10.9%) Death 15 (8.2%) 9 (4.9%) 0.189

14 Complications during STEMI transfer Minor compl. Serious compl. Scene Time p value median (19 min) > median (19 min) 50 (44.2%) 38 (33.6%) (8%) 16 (14.2%) Death 11 (7.1% ) 14 (9.1% ) 0.425

15 Long Term Survival According to EMS UAP, AP, AMI, CA Days

16 Survival in patients with ACS STEMI transferred vs nonste presenters N =293 N =376

17 Conclusions Despite long transfer times in this STEMI population the complications during transfer are acceptable Complications during transfer seem independent of the run times In an ACS population, STEMI patients transferred for ppci have a better long-term survival compared to nonste presenters treated at local Hospitals Non-STE ACS should be managed aggresively and admittance to small regional hospitals may not be the optimal organisation

18 STEMI patienter fra det tidl. Storstrøms amt Tid på skadested median > median (19 min) (19 min) p value STEMI patienter fra det tidl. Storstrøms amt Tid fra skadested til Rigshospitalet median > median (65 min) (65 min) p value Ingen/mindre komplikationer 50 (44.2%) 38 (33.6%) Ingen/mindre komplikationer 67(47.5%) 48 (34.0%) Alvorlige komplikationer 9 (8%) 16 (14.2%) Alvorlige komplikationer 13 (9.2%) 13 (9.2%) Død 11 (7.1%) 14 (9.1%) Død 14 (9.6%) 7 (4.8%) 0.265

19 STEMI patienter fra det tidl. Storstrøms amt Tid fra alarm til Rigshospitalet p value median (92 min) > median (92 min) Ingen/mindre komplikationer 80 (43.5%) 72 (39.1%) Alvorlige komplikationer 12 (6.5%) 20 (10.9%) Død 15 (8.2%) 9 (4.9%) 0.189

20 STEMI patienter fra det tidl. Storstrøms amt Tid på skadested median > median (19 min) (19 min) p value STEMI patienter fra det tidl. Storstrøms amt Tid fra skadested til Rigshospitalet median > median (65 min) (65 min) p value Ingen/mindre komplikationer 50 (44.2%) 38 (33.6%) Ingen/mindre komplikationer 67(47.5%) 48 (34.0%) Alvorlige komplikationer 9 (8%) 16 (14.2%) Alvorlige komplikationer 13 (9.2%) 13 (9.2%) Død 11 (7.1%) 14 (9.1%) Død 14 (9.6%) 7 (4.8%) 0.265

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22 Survival in patients with ACS STEMI transferred vs nonste presenters Variable Total N N of Events STEMI patients treated at invasive center (15.36%) ACS patients treated locally (22.87%) Overall (19.58%)

23 Komplikationsrate under ambulance transport for STEMI patienter Københavns Kommune (n =141) Tidl. Storstrøms Amt (n =293) Ingen eller mindre komplikationer 110 (78%) 247 (84.3%) Alvorlige komplikationer 31 (22%) 46 (15.7%)

24 Komplikationer under transport af STEMI patienter fra det tidl. Storstrøms Amt til Rigshospitalet, registreret i Lægeambulance journal Alvorlige komplikationer Mors 1 (1,7%) Hypotension 8 (13.6%) Dyspnø / Respir.insuff. / Lungeødem 4 (6.8%) VES 4 (6.8%) VF 11 (18,7%) VT 2 (3,4%) Bradykardi 12 (20.3%) Arytmier 3 (5.1%) Lette komplikationer SVT 1 (1,7%) Hypertension 1 (1,7%) Smerter 5 (8,5%) Opkastning 6 (10,2%) Vandladning 1 (1,7%) Total 59 (100,0%)

25 Tentative Konklusioner STEMI patienter fra det tidl. Storstrøms amt visiteret telemedicinsk til Rigshospitalet har signifikant bedre overlevelse end øvrige AKS patienter behandlet lokalt. (univariat analyse, ej korrigeret for alder endnu) STEMI patienter i det tidl. Storstrøms amt fra de yderst beliggende områder med de længste transport tider har samme komplikationsrate under transport ift. dem med kortere transportider fra samme amt, samt samme overlevelse efter ca dages follow up. STEMI patienter fra hele Storstrøms amt har på trods af signifikant længere præ-hospitale tider ingen signifikant øget komplikationsrate under transport ift. STEMI patienter fra Københavns Kommune. Dette taler for at den nuværende præhospitale organisation med telemedicin.

26 Time to reperfusion treatment and complication rate during ambulance transport in STEMI patients transported from Zealand Region to Rigshospitalet for ppci amaria Sejersten, bmichael Treschow, cmette Madsen,. And Peter Clemmensen adepartment of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark; blægeambulancen Region Sjælland; cinstitute of Public Health, University of Copenhagen, Denmark

27 May 2005 January 2008 Region Zealand MD ambulance patients Læge amb patienter n=4168 Trauma and non-cardiac n=2352 SVT/AVB Pludeselig Hjertedød n=310 OBS AMI n=341 AMI n=391 Hjertestop n=73 UAP n=82 AP n=620 Afsluttet PCI ja/nej RH n=265 Lokal n=126 +/- komplikationer under transport til lokal Kompl u/ trans n=51 Ingen kompl u/trans n=217 Bliver på lokal n=x RH senere n=x PCI ja/nej Sammenholdes med Dansk Hjerteregister.

28 Telemedicine based STEMI-Transfer From Bornholm Ambulance Arrival: 15 min ECG 7 min Phone-Calls: 5 min Helicopter-Flying Time: 42 min Medication and Out: 10 min Ambulance to Rønne: 12 min Waiting for Helicopter: 20 min Helicopter Transfer: 40 min ECG to Rigshospitalet: 94 min

29 Results Delay analysis End of Tt Prehospital Thrombolysis min 220 Primary PCI Delays are expressed as median (min)

30 Treatment delay ppci Capital region R eferred patients n= DAILY PRACTISE 2007 Capital region n= 102 Western Zealand n=49, up to 105km S outhern Zealand n=67, up to 180km Median delays (minutes)

31 Consecutive (n=2483) 911 calls for acute heart disorder Frequenc y Percent Valid Percent Cumulative Percent Valid UAP 79 1,9 3,2 3,2 AP ,9 25,1 28,3 AMI 379 9,3 15,6 43,9 Resuscitated cardiac Arrest Sudden Cardiac Death 72 1,8 3,0 46, ,4 12,4 59,2 Obs AMI 336 8,2 13,8 73,1 Hypertension 61 1,5 2,5 75,6 Chronic Ischemic Heart Disease 65 1,6 2,7 78,2

32 Transmission of Tele-ECG registered in PATS Info missing n=93 (14%) Registered ECG n=686 9-month period in 2007 Copenhagen area n=172 (25%) Info missing n=6 Western Zealand n=180 (26%) Southern Zealand n=241 (35%) Info missing n=1 Local hospital n=64 (39%) Invasive hospital n=102 (61%) Local hospital n=131 (73%) Invasive hospital n=49 (27%) Local hospital n=173 (72%) Invasive hospital n=67 (28%)