Telemedicine pre-hospital electrocardiogram for acute cardiovascular disease management in detainees: An update

European Research in Telemedicine/La Recherche Européenne en Télémédecine (2015) 4, 25—32

Available online at

ScienceDirect www.sciencedirect.com

ORIGINAL ARTICLE/TELEDIAGNOSIS

Telemedicine pre-hospital electrocardiogram for acute cardiovascular disease management in detainees: An update Électrocardiogramme pré-hospitalier par Télémédecine pour la gestion des maladies cardiovasculaires aiguës chez les détenus : une mise à jour N.D. Brunetti a,∗, G. Dellegrottaglie b, L. De Gennaro c, M. Di Biase a a

Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71100 Foggia, Italy b Cardio-on-Line Europe s.r.l., Bari, Italy c Cardiology Department, Ospedale S. Paolo, Bari, Italy Received 8 January 2015; accepted 18 February 2015 Available online 11 March 2015

KEYWORDS Telemedicine; Pre-hospital electrocardiogram; Detainees; Penitentiaries; Acute myocardial infarction

∗

Summary Introduction. — Medical assistance for detainees is often hampered by logistic and procedural limitations. Telemedicine may represent the solution by which such limitations can be overcome. We therefore report an update on an experience of remote telemedicine support by pre-hospital electrocardiograms and remote tele-consultation with a cardiologist implemented in a group of Italian penitentiaries. Methods. — Eleven State penitentiaries situated in Apulia (South-Eastern Italy) were provided with a pocket electrocardiogram recorder. The electrocardiograms were interpreted by a remote cardiologist available 24/7, which also gave a brief consultation. Results. — A total 3213 pre-hospital electrocardiograms were performed from January 2008 to October 2014. In 1.1% of pre-hospital electrocardiograms a supra-ventricular tachycardia was found: pre-hospital electrocardiogram showed in 7.2% anomalies suggestive for acute myocardial ischemia, in 0.8% an ST-elevation requiring immediate transfer for primary PCI.

Corresponding author. E-mail address: [email protected] (N.D. Brunetti).

http://dx.doi.org/10.1016/j.eurtel.2015.02.002 2212-764X/© 2015 Elsevier Masson SAS. All rights reserved.

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N.D. Brunetti et al. Clinical indications after pre-hospital electrocardiogram were hospitalization in 29 cases, primary PCI in 26; direct cardiologist referral in 162, a cardiac troponin assay in 142; in 252 cases outdoor further medical examinations were suggested. By converse, thanks to pre-hospital telemedicine screening, immediate hospitalization was avoided in 99% of tele-consultations; in 2961 cases with suspected acute cardiovascular disease detainees were examined with an electrocardiogram without leaving the penitentiary. Conclusions. — Pre-hospital electrocardiogram telemedicine screening strategy in the case of suspected acute cardiovascular disease in detainees is feasible. A single regional telemedicine ‘hub’ may provide support to a region-wide network with 11 penitentiaries and about 3500 detainees. © 2015 Elsevier Masson SAS. All rights reserved.

MOTS CLÉS Télémédecine ; Électrocardiogramme ; Détenus ; Pénitenciers ; Infarctus aigu du myocarde

Résumé Contexte. — L’assistance médicale aux détenus est souvent compromise par des limitations logistiques et de procédure. La télémédecine peut représenter la solution permettant de surmonter ces limitations. Nous rapportons donc une mise à jour sur une expérience de télémédecine à distance par des électrocardiogrammes pré-hospitaliers et télé-consultation à distance avec un cardiologue mis en œuvre dans un groupe de pénitenciers italiens. Méthodes. — Onze pénitenciers d’État situés dans les Pouilles (Italie du Sud-Est) ont été fournis avec un électrocardiographe poche pour l’enregistrement à distance de un électrocardiogramme pré-hospitalier. Les électrocardiogrammes ont été interprétés par un cardiologue à distance disponible 24/7 qui a également donné une brève consultation. Résultats. — Au total, 3213 électrocardiogrammes pré-hospitaliers ont été réalisées de janvier 2008 à octobre 2014. Dans 1,1 % des électrocardiogrammes pré-hospitaliers une tachycardie supra-ventriculaire a été trouvée : pré-hospitaliers électrocardiogramme a montré dans 7,2 % des anomalies suggestives de l’ischémie myocardique aiguë, à 0,8 % une élévation du segment ST exigeant le transfert immédiat pour angioplastie coronaire primaire. Les indications cliniques après l’électrocardiogramme pré-hospitalier étaient hospitalisation dans 29 cas, angioplastie primaire dans 26 ; direct renvoi au cardiologue dans 162, un test de troponine cardiaque dans 142 ; dans 252 cas d’autres examens médicaux ont été suggérées. L’évaluation pré-hospitaliere, au contraire, avec la télémédecine a évitée l’hospitalisation immédiate dans 99 % des téléconsultations ; en 2961 avec des cas suspects de maladies cardiovasculaires aiguës détenus ont été examinés avec un électrocardiogramme sans quitter le pénitencier. Conclusions. — Une stratégie d’évaluation avec l’électrocardiogramme pré-hospitalier et la télémédecine dans le cas de suspicion de maladie cardiovasculaire aiguë chez les détenus est faisable. Une seul télémédecine « hub » régional peut apporter un soutien à un réseau à l’échelle régionale avec 11 pénitenciers et environ 3500 détenus. © 2015 Elsevier Masson SAS. Tous droits réservés.

Introduction Medical assistance for detainees is often hampered by logistic and procedural limitations. Qualified specialists are often not available in all penitentiaries and outdoor transfer for medical referral may often require supervising magistrate authorization and escorts, which may unavoidably delay diagnosis and treatment. The quality of care in penitentiaries therefore does not always meet international benchmarks and standard of quality [1]. Also medical staffs are often underpowered to provide adequate medical assistance to large detainee populations in overcrowded prisons [2]. Telemedicine may represent the practical solution by which to overcome several limitations possibly hampering

the delivery of a qualified specialistic medical assistance, particularly in the field of cardiovascular disease [3] and acute cardiovascular care. We therefore report an update on an experience of remote telemedicine support by pre-hospital electrocardiograms and remote tele-consultation with a cardiologist implemented in a group of Italian state penitentiaries.

Methods Eleven State penitentiaries situated across Apulia (Fig. 1), a region in South-Eastern Italy, were involved in the project, which was supported by Apulia Supervising Authority on Penitentiaries and Regional Health Agency.

Telemedicine and acute cardiovascular disease management in detainees

27

Figure 1. Location of penitentiaries in Apulia and pre-hospital electrocardiogram volumes sent for remote telemedicine consultation. Localisation des établissements pénitentiaires en Apulia et les volumes d’électrocardiogrammes pré-hospitaliers envoyés pour téléconsultation.

Each penitentiary was provided with a pocket ECG recorder (CardioVox P12, Aerotel, Holon, Israel) (Fig. 2), which can record a complete 12-lead electrocardiogram. The electrocardiograms were sent by telephone connection to a regional telecardiology ‘‘hub’’, serving the entire region of Apulia, located in Bari, capital city of Apulia, where a cardiologist available 24/7 promptly interpreted the electrocardiograms and gave a brief consultation. In this short communication, remote contact, usually a prison nurse, sometimes a physician, informed the ‘hub’ cardiologist about detainee medical history, symptoms and physical examination. Electrocardiograms were immediately sent back via the Internet, fax or visualized back on smartphones. Telemedicine support was provided by Cardio-on-Line Europe s.r.l. (Bari, Italy) as previously described elsewhere [4—6]; the telecardiology hub also supports the local public regional emergency medical service (118) of Apulia. The telemedicine service has been established since October 2004 by Cardio-on-line EuropeS.r.l., a telemedicine company certified in UNIENISO9001: 2008 (quality certification) and UNICEIISO/IEC27001: 2006 (security data certification). The telecardiology hub for the entire region, operative 24/7, has two cardiologists on duty for electrocardiogram interpretation, 12 computer terminals, 25 telephone lines, 2 call center operators available 24/7, 20 alternating, on duty cardiologists and an emergency power

system in case of electrical power outage. All center services and the entire network are shielded from virus threats by a combination of hardware and software firewalls, and a comprehensive antivirus, in addition to software back-up procedures. A comprehensive network management program ensures that all systems have real-time updates and that the latest security patches are installed as soon as they are released. All data are electronically stored in computers using a unique identification number for the center and individual, in compliance with the Italian Privacy and Personal Information Protection Act (D. Lgs. 196/2003). Before any electrocardiogram transmission, remote operator must be identified by a site code which is released to authorized personnel only (prison nurses, doctors). Personal identification data are not transmitted with electrocardiogram data, and are matched finally at the end of the workflow when the cardiologist interprets the electrocardiogram. Detainees were immediately referred for direct cardiologist examination or hospitalization in the case of suspected acute cardiovascular disease confirmed at pre-hospital electrocardiogram or after cardiologist consultation. Prison nurses which performed the remote electrocardiograms followed a short training aimed at the acquisition of the skills required for electrocardiogram recording and transmission. The electrocardiograms were recorded in any case of chest pain, palpitations, dizziness/syncope, dyspnea or suspected acute cardiovascular disease, as preliminary

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Figure 2. Scheme of telemedicine electrocardiogram service. Pre-hospital electrocardiograms are sent via telephone connection and directly interpreted by a cardiologist available 24/7. Schéma du service d’électrocardiogramme (ECG) par télémédecine. Les ECG pré-hospitaliers sont envoyés par connexion téléphonique et interprétés par un cardiologue disponible 24 h/7 j.

agreed by regional Health Care Authorities and telemedicine service. The cost for each electrocardiogram and brief consultation was about 15 euros. The study was authorized by local Supervisory Correctional Authorities and Health Agency and is in accordance with the declaration of Helsinki.

Results A total 3213 pre-hospital electrocardiograms were recorded and sent to telecardiology hub from January 2008 to October 2014 (Fig. 3) for interpretation during a 2555-day observation period (mean 1.25 calls per day). Data per single penitentiary are given in Table 1 and Fig. 1. In 74% of days there were 1—2 calls for pre-hospital electrocardiograms (Table 2). Eighty percent of subjects screened by telecardiology had 1—2 electrocardiograms (Table 3). Only 5.4% subjects screened by pre-hospital telecardiology electrocardiogram were female, 19% were older than 60 years (Fig. 4). With an estimated detainees population of 3331 in Apulia penitentiaries, the mean pre-hospital electrocardiogram

per detainee ratio was 1 over 8.8 in the whole observation period. Pre-hospital electrocardiogram findings are given in Table 4. In 1.1% of pre-hospital electrocardiograms a supra-ventricular tachycardia was found: pre-hospital electrocardiogram showed in 7.2% anomalies suggestive for acute myocardial ischemia, in 0.8% an ST-elevation requiring immediate transfer for primary PCI. Clinical indications after pre-hospital electrocardiogram were hospitalization in 29 cases, primary PCI in 26; in 162, direct cardiologist referral was suggested, in 142 a cardiac troponin assay, in 252 further outdoor medical examinations were suggested. By converse, thanks to pre-hospital telemedicine screening, immediate hospitalization was avoided in 99% of tele-consultations. In 82% of cases no further clinical or laboratory examination was required and in 2961 cases detainees were examined with an electrocardiogram without leaving the penitentiary, without any need for magistrate authorization for transfer or escorts. Considering just 321 electrocardiograms performed in penitentiaries located in the Bari, Barletta/Andria/Trani districts in 2014, just 15 detainees were actually urgently hospitalized after telemedicine electrocardiogram (4.7%) by

Telemedicine and acute cardiovascular disease management in detainees

29

35

30

No of obs

25

20

15

10

5

0

Jan-2008

Dec-2009 Mar-2011 Nov-2011 Jun-2012 Oct-2013 May-2014 Sep-2008 Apr-2009 Aug-2010 Feb-2013 Aug-2009 Apr-2010 Feb-2014 Sep-2014 May-2008 Dec-2008 Nov-2010 Jul-2011 Mar-2012 Oct-2012 Jun-2013

Figure 3. Pre-hospital telemedicine electrocardiograms performed in detainees during observation period. Les télé-électrocardiogrammes pré-hospitaliers réalisés chez les détenus pendant une période d’observation.

local emergency medical service (118) and in just 64 cases cardiologist referral was suggested.

Discussion We report 8-year data on a large telemedicine network supporting local penitentiaries in the pre-hospital diagnosis of acute cardiovascular disease in detainees. Prior preliminary data on telemedicine implementation in Italian penitentiaries have been already published [7], but the population hereby reported is significantly larger and data analysis more detailed. Several experiences of implemented telemedicine in penitentiaries have been reported [8—10]. Most of these,

Figure 4. Age of detainees screened by pre-hospital telemedicine electrocardiogram. L’âge des détenus dépistés par télé-électrocardiogramme préhospitalier.

Table 1 Pre-hospital telemedicine electrocardiograms performed during observation period by penitentiary. Les télé-électrocardiogrammes pré-hospitaliers réalisés pendant la période d’observation selon établissement pénitentiaire.

Casa circondariale Lecce Casa circondariale Bari Casa circondariale Taranto Casa circondariale Trani istituto Maschile Casa circondariale San Severo Casa circondariale Brindisi Casa circondariale Foggia Casa mandamentale Altamura Casa circondariale Spinazzola Casa circondariale Trani Istituto Femminile Casa circondariale Lucera Casa di Reclusione Turi

Count

Percent

1799 557 245 180

56.0 17.3 7.6 5.6

179 145 39 31

5.6 4.5 1.2 1.0

20 13

0.6 0.4

4 1

0.1 < 0.1

however, focused on non-cardiovascular fields such as surgery [11], ophthalmology [12] or psychiatrics [13]. Fewer data are available on emergency care; in a study held in New York State penitentiaries, the majority of telemedicine patients remained at the facility following consultation, with just a minority being transported to the emergency department [14]. Interesting preliminary data pointed out possible cost reduction by applying telemedicine support [15—18]. The telemedicine service in Apulia was also utilized for pre-hospital diagnosis of arrhythmias in syncope [19], atypical atrial fibrillation [20], in primary [21,22] and

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Table 2 Number of pre-hospital telemedicine electrocardiograms performed per day. Nombre de télé-électrocardiogrammes pré-hospitaliers réalisés par jour.

Table 4 Pre-hospital telemedicine electrocardiograms findings. Résultats des télé-électrocardiogrammes préhospitaliers.

Calls per day

Count

Percent

Electrocardiogram finding

Count

Percent

1 2 3 4 5 6 7 8 9 11

749 467 248 109 38 15 6 1 1 1

45.8 28.5 15.2 6.7 2.3 0.9 0.4 0.1 0.1 0.1

Sinus rhythm Sinus tachycardia Sinus bradycardia Premature atrial contractions Premature ventricular contractions Paroxysmal supra-ventricular tachycardia Atrial fibrillation Atrial flutter Chronic atrial fibrillation First degree atrio-ventricular block Pace-maker activity Left ventricular hypertrophy Left bundle branch block Right bundle branch block Anterior fascicular block Posterior fascicular block Bi-fascicular block Q-waves Symmetric negative T-waves Asymmetric negative T-waves ST-depression Minor ST-depression Minor ST-elevation ST-elevation acute myocardial infarction ST-elevation acute myocardial infarction + mirror image Artifacts Junctional rhythm Sinus arrest

2901 24 19 56 100 8

90.3 0.7 0.6 1.7 3.1 0.2

24 3 56 21 21 26 27 33 42 1 24 184 120 137 43 10 51 12

0.7 0.1 1.7 0.7 0.7 0.8 0.8 1.0 1.3 0.0 0.7 5.7 3.7 4.3 1.3 0.3 1.6 0.4

14

0.4

43 4 2

1.3 0.1 0.1

secondary prevention of cardiovascular disease [23,24], fast track emergency room triage [25], and in the case of climate emergencies [26]. Logistic requirements and diagnostic findings from Apulia telecardiology network have been previously published [4—6,27]. Despite the fact that pre-hospital 12-lead electrocardiogram assessment in case of suspected acute myocardial infarction has been strongly recommended by guidelines [28] and scientific statements [29], this approach is still underused [30]. However, pre-hospital electrocardiogram triage bypassing emergency department was shown to be associated with lower mortality rates in acute myocardial infarction [31,32]. Relative reduction in ST-elevation myocardial infarction mortality reached dramatic reduction of about Table 3 Number of pre-hospital telemedicine electrocardiograms performed per detainee. Nombre de télé-électrocardiogrammes pré-hospitaliers réalisés par détenu.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18 21 31 Total

Count

Percent

1044 272 139 66 36 17 14 12 10 9 5 2 1 2 2 2 3 1 1 3213

63.7 16.6 8.5 4.0 2.2 1.0 0.9 0.7 0.6 0.5 0.3 0.1 0.1 0.1 0.1 0.1 0.2 0.1 0.1 100.0

60% in recent studies [33]. Rural areas are those with the larger benefit deriving from telemedicine support [34,35]; pre-hospital electrocardiogram triage enables people living far from a PCI facility to achieve a time to treatment comparable with those living closer [36]. Detainees, in a different way a ‘‘remote’’ group of patients, are significantly limited in their mobility and possibility to access qualified medical assistance within the benchmark times. There is a huge need for qualified cardiology assistance in penitentiaries. Official Government Reports reaffirm that telemedicine may be extremely useful in reducing costs and deliver an efficient cardiology care [37]. Nevertheless, prison nurse staffs are often undermanned [38], even for telemedicine implementation. According to recent estimates 4% of the Italian detainees population is affected by cardiovascular disease [39]. According to brief calculation considering the number of detainees in Italian penitentiaries in 2014 (over 49,0002 ) and the Italian attack rates of acute coronary syndrome (33.9/10,000 [40]), the expected rate of incidence of acute myocardial infarction in Italian detainees is about 166 cases per year. In such population with an expected case of acute

Telemedicine and acute cardiovascular disease management in detainees myocardial infarction suggested time to reperfusion could be hardly achieved without a pre-hospital electrocardiogram. In our population, 26 cases of ST-elevation acute myocardial infarction were actually observed, in line with detainees’ population in Apulia (3540 in June 2014 [41]) and the presumed rates of incidence of non-ST-elevation acute myocardial infarction. In 99% of cases, hospitalization was excluded and in 2961 further costs in terms of jailer, escorts, surveillance personnel and transportations were avoided. Global cost analysis, however, is not easy, since the exact cost required for each detainee’s outdoor transfer for medical examination is not exactly quantified. In a prior cost analysis performed in the setting of our regional Emergency Medical Service supported by remote electrocardiogram telemedicine assistance, impressive potential cost reductions (1 to 4 millions euros per year) and very interesting cost ratios have been shown (49 euros per every pre-hospital diagnosis of acute cardiovascular disease, 1927 euros per every quality adjusted life year (QALY) gained just considering exclusively subjects diagnosed with ST-elevation acute myocardial infarction) [42]. Given the total costs for the service and the number of ST-elevation acute myocardial infarction pre-hospitally diagnosed, even better cost ratio could be theoretically presumed in this penitentiary scenario. However, in spite of any presumable cost reduction, several thousands of men and women were given a further chance to be examined with an electrocardiogram in the case of suspected acute cardiovascular disease without any avoidable delay.

[5]

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[12]

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Conclusions A pre-hospital electrocardiogram telemedicine screening strategy in the case of suspected acute cardiovascular disease in detainees is feasible. A single regional telemedicine ‘hub’ may provide support to a region-wide network with 11 penitentiaries and about 3500 detainees.

[15] [16]

[17]

[18]

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.

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