Heart to heart: city and country coronary survival stats draw equal in SA
Whether you live or die from a heart attack in Australia is quite literally affected by your address at the time of your myocardial infarct (MI). When cardiac physician Dr Phil Tideman and medical scientist Rosy Tirimacco started their quest to improve the treatment and outcomes for acute cardiac patients in regional, rural and remote South Australia, in 2001, the 30-day mortality rate for city folk suffering heart attacks in that state was 12.4%; for country people it was 18.4%. This disparity is mirrored, to varying degrees, in every Australian state. In SA, it took nine years of implementation of strict protocols of care and collaboration between health-care providers across all areas of cardio health, to shift the needle on those figures and bring them into line. Now the plan continues to roll out across state lines, and into the digital era with GE’s machine-to machine technology. Investment in networked digital electrocardiograph (ECG) machines for each of 66 South Australian country hospitals is making specialist care easily available to all postcodes.
The successful project is known as the Integrated Cardiovascular Clinical Network, Country Health South Australia, or iCCnet.
South Australia has about 1.68 million people, spread unevenly over about one million square kilometres. While most people live the metro life, more than 600,000 call the rural areas home. “We managed to prove that by providing care providers in country areas with the appropriate systems and tools to be able to practice evidence-based cardiology, they can have the same mortality rates as the city population,” says Tideman, clinical director of iCCnet. “That’s the paper we published in the Medical Journal of Australia in February last year, and that data is now being accepted as a new standard of care for rural cardiology and particularly acute coronary syndromes.”
So what did iCCNet provide that country services couldn’t access before? Primary was a commitment to equipping health carers and hospitals in rural areas to apply accepted protocols of best-practice cardiac treatment in 100% of cases. When Tideman and Tirimacco began the research phase of iCCnet, in the 1990s, “The lack of access to care was endemic. Doctors in country towns didn’t have point-of-care pathology, they didn’t have ECGs they could pass by a cardiologist, they didn’t have automatic seamless transfer into a tertiary centre for a patient who had a heart attack”, explains Tideman.
iCCnet set immutable standards for country hospitals along evidence-based medical guidelines. For example, iCCnet ensured each hospital had the capability to do the standard troponin blood test to detect heart damage onsite. In addition, they had a supply of acute medications, staff training in applying protocols and timely access (via the Royal Flying Doctor Service) to larger hospitals for surgical interventions when necessary. The onsite ECG machines were paired with access to on-call consultant cardiologists who would respond within 10 minutes to faxed ECG results, giving expert interpretation and advice on the next best course of action.
By 2008 iCCnet had been rolled out to all the state’s 66 rural hospitals and was showing good outcomes on various indicators: 30-day mortality, an increased rate of transfer of rural patients to metropolitan hospitals, and a lower total length of stay in hospital. But with “continuous quality improvement in the management of cardiovascular disease” being central to iCCnet’s mission, Tideman’s team began looking to digital ECGs. At Flinders Medical Centre, Tideman had worked with MUSE, GE’s networked ECG system on a hospital-wide basis, since 1998.
The difference between analogue and digital systems was both in the quality of the ECG image and the ability to deliver the information to everyone involved in caring for a patient, and Tideman envisaged that digital systems would allow aggregation of masses of comparable data that would ultimately drive still greater improvements in results.
“We implemented a state-wide digital ECG system in 2010/11. It cost about $1.2 million to buy all the new GE MAC 550 ECG machines, the servers and the software and to set all that up, but it works fantastically,” says Tideman. Each of the 66 hospitals received an ECG cart, which was digitally hooked up to the IT network. Every ECG result is sent to a central database in Adelaide. “We can send it out to the cardiologists on call, either as an email or they can tap into the system on an iPad,” says Tideman. “We’ve eliminated the tyranny of distance in terms of clinical management, which is very, very important.”
The GP at home in Naracoorte, five kilometres from where the patient is in hospital, and the cardiologist 330 kilometres away in Adelaide, have access to the same high-quality data. They can easily confer with each other and also with country-hospital nursing staff. “All of these people being able to communicate seamlessly is really the secret of getting a good network running,” adds Tideman.
We’ve eliminated the tyranny of distance in terms of clinical management, which is very, very important.
“I worked as an emergency-care physician in the rural areas, in places like Rockhampton in Queensland,” says GE’s David Dembo, general manager of Healthcare Solutions, GE Australia. “I have a sense of what it’s like to try to practise medicine where you don’t have the spectrum of specialists available to you. Machine-to-machine logic lets you do tests and send results, almost in real-time to a metropolitan area where an on-hand specialist can read it as fast as if the patient were down in emergency in the metropolitan hospital.” Machines talking to machines, he says, “Removes the illogical expectation that a specialist should have to drive to the facility to be able to look at an image … which is just crazy. MUSE is one way in which we’ve broken down the walls of the hospital, so that it doesn’t matter where the clinician is, so long as they can connect via technology to the image we’ve created.”
Tideman says that he’s looking forward to being able to aggregate and share information in large volumes on a continuous basis—“to get information on how people are performing in the system, and how patients are faring in the system”. In the past, that required sifting through paper- and computer-based case notes, but as Australia moves towards electronically stored medical records of all kinds, cracks in the system will be more easily identified. Tideman also anticipates being able to program a system to raise red flags—say, when an acute country-based cardiac patient who shows all signs of needing transfer to a metro hospital is not transferred, it will alert healthcare staff to investigate. “There may be a good reason. The patient might be 95 years old and doesn’t want to go to town. Or they’ve had previous bypass surgery and aren’t suitable for further surgery. But most of the time, those patients should be transferred. So by combining the data and monitoring it all the time, we can put safety checks into the system that haven’t existed before.”
After 14 years in operation, iCCnet is now “embedded in the operation of Country Health SA, with permanent staff and a budget, so we don’t have to go chasing funds all the time,” says Tideman. The Northern Territory has replicated iCCnet’s model, and Western Australia and Victoria are adapting the system to their different geographical needs. In the meantime, GE has adapted its MUSE ECG management system to operate with non-GE machinery, allowing hospitals with other equipment to expand the functionality of their ECG investment.
In South Australia,Tideman says the interoperability of the GE system alone provides accumulated information on long-term outcomes and also on cost effectiveness: “It’s very important that we get data on cost-effectiveness, because it doesn’t cost very much to run the network, and we believe if in South Australia we’re saving 60, 80, 100 lives a year, then the cost benefit is extremely good!”
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