| | The role of continuous monitoring in a 24/7 telecardiology consultation service—a feasibility studyReceived 18 April 2009 published online 21 August 2009. Abstract Today's coronary care unit patients include those with complicated and uncomplicated myocardial infarction, decompensated heart failure and frank cardiogenic shock, severe valvular heart disease, high-grade conduction disturbances, and incessant ventricular arrhythmias. Increasingly in modern medicine, these conditions are not seen in isolation but rather in connection with a series of additional medical comorbidities. Increased life expectancy results in an increase in the prevalence of chronic cardiovascular diseases and an increased demand for health care services. Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of a patient. Telecardiology is one of the oldest applications in telemedicine and has been largely applied during the last 10 to 20 years. This study evaluated the feasibility of remote surveillance of coronary care unit and cardiology ward patient monitoring data by a “telecardiologist” with access to electronic health care record data and digitally stored 12-lead electrocardiograms. The remote access to the hospital intranet proved to be technically feasible. Also, the server applications used over the remote connection proved to be reliable and showed robustness against network performance variations. Extending remote patient surveillance to other hospitals is possible, provided that similar electrocardiogram and electronic health care record applications are available and a remote access can be arranged to them. However, the usability from cardiologist's perspective may be degraded if connecting with multiple applications and hospital networks is needed. The study indicated potential for speeding up the diagnostic and therapeutic processes in the hospital, although the study was limited in that the telecardiologist played a passive role and did not acutely impact patient care. In the future, the system could be expanded to surveillance of smaller hospitals. Telemedicine has the potential to aid in solving the conflict between aging of population, rise in the demand for critical care services, and shortage of professional personnel. This might, however, require a more active remote surveillance than the one tested in this study. Privacy- and security-related aspects are major components of building trust and confidence in telemedicine systems. In telecardiology, the real-time interactive telemedicine model with 24/7 service has potential superior performance compared with a store-and-forward telemedicine model. Introduction  The first description of the coronary care unit (CCU) was presented in the early 1960s by Julian1 and Killip and Kimball.2 It soon became evident that improvements in mortality for acute myocardial infarction (MI) could be achieved by treating patients in a CCU rather than a regular ward setting. The CCU today, however, is a very different landscape compared with that in the 1960s.3 No longer is it simply an observation unit for patients with acute MI, but today's CCU patients include those with complicated and uncomplicated MI, decompensated heart failure and frank cardiogenic shock, severe valvular heart disease, high-grade conduction disturbances, and incessant ventricular arrhythmias. Increasingly in modern medicine, these conditions are not seen in isolation but rather in connection with a series of additional medical comorbidities. Increased life expectancy results in an increase in the prevalence of chronic cardiovascular diseases and an increased demand for health care services. Also, diabetes and its associated complications are part of a chronic disease global epidemic that presents a public health challenge. As the average age of the population continues to increase globally, the demand for critical care services is expected to rise rapidly. The breadth of critical care diseases and the remarkable patient diversity now seen in the CCUs represent a challenge to the general cardiologists and specialists in internal medicine that currently staff these units. At the same time, there will be a significant shortage of physicians trained in critical care who will be available to meet these demands. In the United States, it has been estimated that by 2020, there will be a deficit of intensivists that is equal to 22% of demand, and by 2030, this deficit will approach 35%.4 Telemedicine Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of patients.5 Despite the potential of telemedicine, its benefits and the technical maturity of the applications, the use of telemedicine services is still limited, and the market remains highly fragmented. Integrating new types of services in health care services is a challenging task (Commission of the European Communities: COM [2008] 689). Privacy- and security-related aspects are also major components of building trust and confidence in telemedicine systems. Interoperability and standardization in telemonitoring are crucial to allow widespread use of the technologies. The societal and economic benefits from wider use of telemedicine are potentially huge. At the present moment, they are far from being fully appreciated or achieved.6, 7 Telecardiology Telecardiology is one of the oldest applications in telemedicine and has been largely applied during the last 10 to 20 years.8 Telecardiology encompasses a wide variety of applications. More than 200 000 patients worldwide are being managed via remote implantable electronic cardiovascular device (IECD) monitoring to facilitate the recognition of abnormal device behavior and verify the patient's immediate physiologic response to the many programmable therapies IECD offer.9 Data collected in several completed and ongoing studies strongly suggest that this new technology will make important contributions, particularly with respect to the facilitation of IECD follow-ups, enhancement of patient safety and quality of life, and lowering of medical costs. Continuous home monitoring of vital parameters such as weight, blood pressure, and heart rate, using external telemedicine devices, can improve outcomes in heart failure patients.10, 11, 12 Telecardiology applications can be categorized as prehospital, in-hospital, and posthospital.13 The major purpose of prehospital 12-lead electrocardiogram (ECG) diagnosis is the early detection of acute MI with ST-segment elevation and the communication of that information to the receiving emergency physician before the arrival of the patient.14 In-hospital telecardiology is used between small hospitals in rural regions and main hospitals.15 Telemedicine here has the potential to improve access to echocardiography diagnoses in the intensive care unit (ICU), emergency room, and newborn nursery. A video link between the echocardiographic and videoconferencing equipment at the remote center allowed the specialist to view images in real time.16 Posthospital applications include teleconsulting between general practitioners and specialists, home telenursing for chronic cardiac diseases, and the diagnosis of arrhythmias.17, 18 Telecardiology is one of the fastest growing fields in telemedicine. There is already a significant quantity of published clinical data, but randomized trials are needed to better define medical and economical benefits of telecardiology.13, 19 Telecardiology in some fields such as emergency and chronic care undoubtedly improves the quality of health care and helps to contain rising costs. Publications related to telecardiology surveillance of CCU monitoring data outside hospital are scarce and mostly deal solely with technical aspects. Feasibility study design Aim of the study The aim of the present study was to evaluate technical and medical aspects of remote surveillance by a cardiologist dedicated to telemedicine (“telecardiologist”) of CCU and cardiology wards in a university hospital. The Heart Center in Tampere University hospital is a tertiary care medical unit with 24/7 cardiology, cardiac surgery, and cardiac anesthesiology service. The CCU consists of 2 separate units (modules) with 16 beds (7 + 9). Patient groups in the CCU include surgical patients, typically postbypass surgery, if their medical condition does not require intensive care with mechanical ventilator, but is not stable enough to allow treatment in a general surgical ward. The cardiology wards consist of 3 modules with 37 beds in total (12 + 12 + 13). Monitoring device technology The Heart Center is equipped with the Philips Medical Systems' IntellieVue patient monitoring system. Collected data are stored online to the central station (Information Center) providing instant access to clinical staff from anywhere in the hospital and also from remote locations. For continuous ECG monitoring, 5 electrodes in the EASI (Philips Medical Systems, Andover, MA) positioning are used.20, 21, 22, 23, 24 The system generates a reconstructed 12-lead ECG through mathematical transformations. All the CCU and most cardiology ward patients are equipped either by bedside monitors or telemetry. CCU and cardiology ward personnel During office hours, cardiologists are in charge of the patients in the CCU and in the cardiology wards. Subspecialists, like electrophysiologists, are consulted if necessary. Nurses in the CCU and in the wards are responsible for handling IntelliVue alarms. All alarms with potential clinical importance are evaluated by a cardiologist or a cardiology fellow or in urgent cases during off hours by the physician on duty. One specialist in internal medicine or a fellow in cardiology is on duty in the hospital and is primarily responsible for the patients during late evenings and nighttime. The interventional cardiologist is in the hospital from 8 am until early evenings during weekdays. During late evenings and nighttime, the invasive cardiologist is on call at home. Telecardiology service arrangement The telecardiology service is provided by TeleKardio Ltd. The company works in close connection with the Heart Center and offers real-time interactive tele-electrocardiogram (ECG) consultations providing cardiologist analysis of ECG findings and proposals for patients care, like modification of medication, and need for further noninvasive or invasive evaluation.25 TeleKardio aims to provide comprehensive telecardiology services, including remote follow-up of implanted devices and home monitoring of patients with chronic diseases, like heart failure. Remote surveillance of CCUs and cardiology wards is a potential future telecardiology application. Study layout During the period from March 16 to April 15, 2009, the telecardiologist tested remote surveillance 5 days a week (Monday through Friday = 21 weekdays) from 5 pm to 6 am. All alarms from the IntelliVue central monitor were checked during a “virtual round” in the evening and the next morning. Also, the ST display, showing one complex from each of the 12 derived EASI leads at a chosen time point, was checked. If necessary, central station data were analyzed from the IntelliVue displays of 12-lead EASI ECG, event surveillance, and trends for heart rate, oxygen saturation, blood pressure, premature ventricular beats, lead-specific ST-deviations, and others (Fig. 1). Personnel in the hospital were requested to contact the telecardiologist in case of need for consultation. The aim was not to intervene actively in patient treatment during the 13-hour remote follow-up period, unless a consultation was requested, or a potentially life-threatening situation was observed without adequate reaction to the incident by hospital personnel. The telecardiologist also had access to the patients' electronic health records (EHRs) and to the digitally stored 12-lead ECG MUSE software (GE Healthcare, Milwaukee, WI). The number and type of central monitor alarms were studied, to predict possible situations, where an intervention from the telecardiologist could improve patient care. It should be pointed out that the aim of the study was not to have continuous remote surveillance of the central monitor data, but to use a system with low requirements for telecardiology personnel and technical equipment. Technical aspects Remote access from the telecardiologist's laptop computer to the hospital was handled by a virtual private network (VPN) arrangement as shown in Fig. 2. The VPN solution (Secgo software, Birdstep Technology ASA, Oslo, Norway) provided a secure connection to the hospital intranet based on smart card authentication. A fixed Internet connection using an Asymmetric Digital Subscriber Line (ADSL) was used as the physical access technology. Wireless 3G (third generation of telecommunication) connection was also available but was not used in the pilot. Using the remote VPN access and a standard browser, the telecardiologist was able to access the IntelliVue Information Center. For accessing the EHR and the MUSE ECG archive, the respective client applications were used instead of the browser. Results General The categories of clinically significant alarms are reported in Table 1. Typical nonsignificant alarms were motion artifacts and “missed beats” in patients with atrial fibrillation. The number of alarms per patient per “virtual round” varied from zero to 120 alarms. Time spent per “virtual round” varied from 20 to 45 minutes, depending on the number of patients and number and character of the alarms. The mean number of patients encountered during a “round” was 28 (minimum of 13 and maximum of 35). Technical aspects The overall technical performance of the remote access was good. There were no situations when access to the intranet was not possible. A few times, the operator ADSL router was disconnected for unknown reasons. In these cases, the connection could be reestablished by restarting the laptop after the ADSL router was booted. On one occasion, the hospital intranet was extremely slow, but access to the IntelliVue Information Center, the patients' EHR, and the MUSE ECG archive was still possible. Arrhythmias Most monitor alarms (Table 1) were bradyarrhythmias or tachyarrhythmias. Sustained ventricular tachycardia (VT) is a potentially life-threatening arrhythmia. All episodes detected by the telecardiologist were also detected by nurses and/or physicians in the hospital. All sustained VTs occurred in patients who either had prior history of implantable cardioverter defibrillator device and of sustained VT or were admitted to hospital due to recent onset VT. There was no need for the telecardiologist to intervene in these cases. The therapeutic interventions by the implantable cardioverter defibrillator system could be appreciated by the remote follow-up (Fig. 3). Nonsustained ventricular tachycardia (NSVT) was a frequent reason for monitor alarm in patients with severe heart failure and after bypass surgery. In 1 patient, the telecardiologist alerted the electrophysiologist during office hours about the need for invasive evaluation with endocardial biopsy due to frequent bursts of NSVT despite amiodarone therapy (Fig. 4). The decision to intervene was based on data from the monitor alarm complemented by data from the EHR. In this patient, the etiology of the NSVT was unknown. Episodes with atrial fibrillation with rapid ventricular response were frequent and typically observed in patients with severe heart failure, and as such not an indication to intervene by the telecardiologist (Fig. 5). Neither was there any case necessitating intervention in patients with atrial flutter with high ventricular rate because these patients had a diagnostic and therapeutic planning performed by an electrophysiologist. In patients with II and III degree atrioventricular block, the cardiologists or cardiology fellows in the ward organized for pacemaker implantations during office hours. The decision for pacemaker implantation could have been done earlier if the telecardiologist had intervened in the patient care more actively. One potentially fatal incident, where a patient had loss of capture through a temporary epicardial pacemaker lead postcardiac surgery with severe bradycardia, was treated by immediate insertion of a transvenous pacemaker lead (Fig. 6). This incident was noted by the telecardiologist hours later during the “virtual round.” The situation had been handled adequately in the CCU. Theoretically, if not adequately treated by the personnel in hospital, intervention by the telecardiologist would have required 24/7 real-time interactive telemedicine service, which was not tested in this feasibility study. Ischemia A few cases with significant ST changes in the lead-specific trend curves were observed in the 12-lead monitor display (Fig. 7). One patient with frequent supraventricular tachyarrhythmias admitted to the hospital for further diagnostic evaluation showed signs of silent ischemia in the EASI 12-lead ECG monitoring. The findings were verified by comparison with the patients' MUSE ECGs. In this case, the electrophysiologist was alerted by the telecardiologist about the need for diagnostic coronary angiography. No action had been taken by the physicians in charge of the patient. One patient showed new ST elevations in leads V1 to V3 in the 12-lead ECG display within the first few hours postprimary percutanous coronary intervention. The ST segments were normal, and the T waves were inverted in the inferior leads II, III, and aVF. New ischemia was suspected, but the patient's EHR revealed the probable cause for the new ECG changes. The patient had an acute inferior ST-elevation MI with thrombotic occlusion of the right coronary artery. Two stents were implanted resulting in stent jail with total occlusion of the right ventricular side branch. The side branch was still occluded at the end of the procedure, but the patient was asymptomatic and clinically stable. Hence, the interventionist decided not to attempt to reopen the side branch through the stent. The importance of recognizing this special ECG pattern, ST elevations in the right precordial leads immediately after stenting of the right coronary artery, has been pointed out previously by our group.26 There was no action taken by the telecardiologist because the data were encountered late during the next virtual round. Artifacts One has to be aware of the false alarms during continuous follow-up because of the artifacts typically induced by patient movement or loose electrodes. In the present study, the alarm display showed data from 2 EASI leads, and in most cases, artifacts could be differentiated from tachyarrhythmias by analyzing both leads (Fig. 8). In some cases, 12-lead EASI display, showing more than 1 QRS complex, was used to for differential diagnostics. In 1 patient with successful primary percutanous coronary intervention with short delay from symptom onset to intervention, deep Q waves unexpectedly appeared in the inferior leads in the EASI ECG. The nurse report in the EHR revealed that the changes had been noted by the CCU personnel and that the patient was asymptomatic. Soon the Q waves disappeared, apparently due to patient position change. Patient outcome was uneventful. On 4 instances, ST-segment trends indicated ischemia during follow-up. In all cases, it was evident from the EHR that the patients were planned for urgent coronary angiography and that the medication was optimal. Hence, there was no need for telecardiology intervention. Discussion As a combination of medical information and telecommunication technologies, telemedicine has the potential to support diagnostics and follow-up of acute and chronic cardiovascular diseases. It is also an appropriate means to solve the conflict between aging of population, rise in the demand for critical care services, and shortage of professional personnel, which are the actual condition and inevitable developing trend of the society not only in developed countries.27 This study evaluated the feasibility of remote surveillance of CCU and cardiology ward patient monitoring data by a telecardiologist with access to EHR data and digitally stored 12-lead ECGs. Security issues are major challenges for telemedicine systems. The VPN-based remote access to the hospital intranet proved to be technically feasible. The server applications used over the remote connection proved to be reliable and showed robustness against network performance variations. Extending remote patient surveillance to other hospitals is possible provided that similar ECG and EHR applications are available and a remote access can be arranged to them. However, the usability from cardiologist's perspective may be degraded if connecting with multiple applications and hospital networks is needed. The access to the required ECG monitoring applications and the EHR may also be provided by mobile applications. This approach offers interesting possibilities because the cardiologist would not be bound to a certain location to support the care process. However, currently, the commercial availability of such systems, as described by Zhang et al,27 is limited. As expected, most significant monitor alarms during the study were related to arrhythmias. In general, the advantage of the remote follow-up was/could have been achieved by alerting treating physicians immediately during office hours to speed up the diagnostic and therapeutic process. This also has the potential to improve planning of the time schedule in the catheterization laboratories. The cardiologist in charge of the invasive procedures can be informed about patient need for pacemaker implantations, coronary angiography, or other invasive procedures already in the morning. In daily routine practice, the need for invasive procedures is appreciated later during the day as the physicians in the ward start their rounds. Also in this study, in some cases, electrophysiologists involved in patient care were informed immediately in the morning about patient need for permanent pacemaker implantation, or for invasive diagnostic procedures, such as endomyocardial biopsy, coronary angiography, or electrophysiologic studies. In the present study, there was no apparent need for telecardiologist intervention to speed up the diagnostic invasive evaluation in patients with unstable angina. This fact could be explained by widely implemented logistic networks for acute coronary syndromes in our hospital district. Patients with ST-elevation MI will almost exclusively have immediate angiography, usually with stenting. Patients with unstable angina or non–ST-elevation MI will have angiography within 24 to 48 hours. The fact that there was no apparent need for immediate telecardiologist intervention in this study does not exclude a potential for this type of service. The remote ICU telemedicine model introduced during the last few years not only expands the geographic range of ICU physicians but also allows a single specialist to simultaneously monitor multiple patients on a continuous basis by leveraging computerized “intelligent” algorithms and an electronic medical record interface.28 The remote ICU represents a “re-engineering” of how ICU care is delivered and establishes a new paradigm for the field of telemedicine, expanding the reach, scope, and availability of intensivist specialty expertise. Preliminary data suggest effectiveness in improving ICU quality of care, thus leading to reductions in the cost of ICU care, ICU patient mortality, ICU patient outliers, and ICU length of stay.29, 30 Proactive remote “virtual rounds” may contribute to the success of this system. Also, there are key elements of error reduction with remote surveillance. Smaller hospitals may benefit from remote CCU and cardiology ward telecardiology surveillance. The acute problems encountered in these hospitals may be as challenging as in the larger hospitals, although there is shortage of specialists involved in patient care. Clinically, significant alarms may pass without proper action more often in small hospitals where the frequency of alarm encounter is smaller than in a university hospital. The possible benefits of remote telecardiology surveillance of smaller hospitals should be tested prospectively in future studies. The telemedicine connection could be continuously available in a proactive fashion that can be provided on a 24/7 basis. Additional personnel would be required for more intense surveillance. The traditional physician, nurse, and patient relationship can be substantially augmented when there is a specialist immediately available to address issues in patient care, particularly at night when physicians are less likely to be present at the bedside. Some patients may benefit from immediate transport to an invasive hospital during off hours. A telecardiologist at a remote location familiar with the medical problem could act as a consultant to speed up the therapeutic process. In this feasibility study, the telecardiologist played a rather passive role. Monitoring data were accomplished by reading the nurse and physician reports and comparing with the digitally stored ECGs, if needed. A more active role with telephone contact between the telecardiologist and the personnel in hospital requires 24/7 telemedicine personnel. Telemedicine systems with 24/7 service exist (http://www.maccabi4u.co.il).13, 19, 31, 32, 33, 34, 35, 36 Large case volume is required for these systems to be effective. One way to achieve large volume for telecardiology centers is operating in different telecardiology applications with comprehensive telecardiology service.34 In telecardiology, a real-time interactive model has certain advantages compared with the traditional store-and-forward model typical for teleradiology. In cardiology, acute problems like ischemic ST elevations might necessitate immediate intervention. This poses challenges to the traditional way of working with consultation requests to busy interventionists who might not be available for immediate response. Conclusions A feasibility study with secure telecardiology remote surveillance central monitor data of a university hospital's CCU and cardiology wards proved technically feasible. The study indicated potential for speeding up the diagnostic and therapeutic processes in the hospital, although the study was limited in that the telecardiologist played a passive role and did not acutely impact patient care. In the future, the system could be expanded to surveillance of smaller hospitals. Telemedicine has the potential to aid in solving the conflict between aging of population, rise in the demand for critical care services, and shortage of professional personnel. This might, however, require a more active remote surveillance than the one tested in this study. Privacy- and security-related aspects are major components of building trust and confidence in telemedicine systems. In telecardiology, the real-time interactive telemedicine model with 24/7 service has potential superior performance compared with a store-and-forward telemedicine model. Acknowledgments The authors wish to thank Registered Nurse Jari Piitulainen for technical support in organizing the study and Data Communications Engineer Timo Asumaniemi for figure preparation. References 1. 1Julian DG. Treatment of cardiac arrest in acute myocardial ischaemia and infarction. Lancet. 1961;2:840. MEDLINE 2. 2Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol. 1967;20:457. MEDLINE |
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a Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland b VTT, Technical Research Centre of Finland, Espoo, Finland  Corresponding author. Department of Cardiology, Heart Center, Tampere University Hospital, Biokatu 6, 33520 Tampere, Finland.
PII: S0022-0736(09)00277-5 doi:10.1016/j.jelectrocard.2009.07.005 © 2009 Elsevier Inc. All rights reserved. | |
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