Original Contribution
Time-to-reperfusion in STEMI undergoing interhospital transfer using smartphone and WhatsApp messenger,☆☆

https://doi.org/10.1016/j.ajem.2015.07.029Get rights and content

Abstract

Objective

The objective of this study is to assess the efficacy of WhatsApp application as a communication method among the emergency physician (EP) in a rural hospital without percutaneous coronary intervention (PCI) capability and the interventional cardiologist at a tertiary PCI center.

Background

Current guidelines recommend that patients with ST-segment elevation myocardial infarction (STEMI) receive primary PCI within 90 minutes. This door-to-balloon (D2B) time has been difficult to achieve in rural STEMI.

Methods and results

We evaluated 108 patients with STEMI in a rural hospital with emergency department but without PCI capability to determine the impact of WhatsApp triage and activation of the cardiac catheterization laboratory on D2B time. The images were obtained from cases of suspected STEMI using the smartphones by the EP and were sent to the interventional cardiologist via the WhatsApp application (group 1, n = 53). The control group included concurrently treated patients with STEMI during the same period but not receiving triage (group 2, n = 55). The D2B time was significantly shorter in the intervention group (109 ± 31 vs 130 ± 46 minutes, P < .001) with significant reduction in false STEMI rate as well.

Conclusion

This study demonstrates that use of WhatsApp triage with activation of the cardiac catheterization laboratory was associated with shorter D2B time and results in a greater proportion of patients achieving guideline recommendations. The method is cheap, quick, and easy to operate.

Introduction

Total ischemic time affects mortality in those patients presenting with ST-segment elevation myocardial infarction (STEMI) [1]. Current guidelines have recommended that the interval between arrival at the hospital and restoration of coronary flow to the ischemic myocardium be 90 minutes or less as a system goal [2]. Primary percutaneous coronary intervention (pPCI) seems to be superior to fibrinolytic therapy in achieving myocardial reperfusion if performed within 90 minutes [3]. Rural STEMI care networks may be particularly disadvantaged in achieving this benchmark for patient-, transport-, and hospital-related delays.

For communication between the emergency physician (EP) and the interventional cardiologist in STEMI, the most frequently used method is a verbal report via telephones. Telephone communication can be rapid but not objective and precise. More recently, photographs taken by smartphone were transferred to another smartphone [4]. WhatsApp (WhatsApp Inc, Mountain View, CA) is an increasingly popular mobile messaging application available on all smartphone platforms.

WhatsApp triage has been advocated as a means to identify patients with STEMI earlier by an EP, activate the cardiac catheterization laboratory (CCL) earlier, and minimize interhospital-based delays to improve total door-to-balloon (D2B) time. This study aims to evaluate, for the first time, the use of WhatsApp for facilitating communication between the EP in a rural hospital without PCI capability and the interventional cardiologist at the PCI hospital to achieve guideline recommendations.

Section snippets

Methods

Between January 2015 and May 2015, a total of 114 patients with suspected STEMI were prospectively enrolled from a rural hospital without PCI capability and subsequently underwent pPCI at our institution. The health care network covers an area of 11,977 km2 and provides care for a primary population of 750,000 people. On average, 650 to 700 patients with STEMI are referred each year to the our center for primary PCI, and approximately 60% of these patients are referred directly from the rural

Results

We identified 108 patients with STEMI treated during the study period. Fifty-three patients underwent WhatsApp triage (group 1), with 55 patients available as a contemporary control, not receiving triage but with activation of the CCL through the EP (group 2). The baseline characteristics are detailed in the Table. A total of 114 patients had been evaluated, but 5 of the patients were diagnosed with non-STEMI on hospital arrival in group 2. Percutaneous coronary intervention was not performed

Discussion

The development of smartphones opened up a new opportunity to integrate mobile technology in daily clinical practice [6], [7]. In addition, the development of new applications facilitated communication among users by improving the taking, storage, and transmission of images [7], [8]. The release of WhatsApp Messenger proved even more useful. This is the first study of WhatsApp triage and early activation by an EP. We observed shorter D2B times and a greater proportion of patients achieving

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Conflict of interest: none.

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