UPAs reduce time for diagnosis and treatment of infarction – 06/27/2023 – Health

The use of telemedicine to support UPAs (Emergency Care Units) across the country has managed to reduce the time taken to diagnose and start treatment for acute myocardial infarction, and is already showing signs of a drop in mortality.

A survey carried out in 30 units shows a reduction of 75% in the time to perform the electrocardiogram in a person who arrives with chest pain and other signs of infarction at the units: from 55 minutes, on average, to 14 minutes. The recommended time is ten minutes.

Between the arrival of the patient with symptoms and the beginning of the medication, it went from 130 to 57 minutes (a decrease of 56%). The ideal is 30 minutes. On average, 80% of the evaluated patients received drugs indicated in cases of acute coronary syndrome, such as ASS, clopidogrel, heparin and statins. The goal is that 85% receive it.

The initiative is funded by the Ministry of Health and carried out by two hospitals in São Paulo, Hcor and BP (A Beneficência Portuguesa de São Paulo), through the Proadi-SUS program, financed with tax immunity resources granted to philanthropic institutions of excellence.

In all, 300 UPAs from the five regions of the country participate in the project, which are served by the telediagnosis and teleconsulting services of these hospitals. These units are today the entry point for most patients with some urgency.

It works like this: the patient with symptoms of infarction or arrhythmia undergoes the catheterization, the exam is sent through a platform to the partner hospitals. The cardiologists on duty (who work seven days a week, 24 hours a day) analyze the exam, issue the report and, via video call, guide the UPA team in conducting the case.

A Sheet accompanied one of these consultations at UPA 26 de Agosto, in the east zone of São Paulo, last Thursday (22). Admitted to the unit for three days to treat complications of a serious genetic syndrome, William do Nascimento, 35, had presented a tachycardia of 198 beats per minute. The examination was performed at the bedside.

At the other end, at BP, cardiologist Hadrien Balzan analyzed the exam, issued the report and started a video call with colleague Leonardo Narciso, a cardiologist at the UPA, to discuss the case. Cardiac arrhythmia was ruled out. “It was really just the effect of the noradrenaline that we are using to sustain his pressure”, says Narciso.

In addition to electrocardiogram devices, the units participating in the project received notebooks that allow real-time video cardiology consultations. Until January of this year, consultation was only done by telephone.

“Doctors manage to look each other in the eye, there is greater confidence in accepting the guidelines that are being given. They say: ‘Wow, you really exist, I thought you were a robot”, says cardiologist Rodrigo Almeida, from BP.

UPA 26 de Agosto, administered by Hospital Santa Marcelina, serves a population of almost 1 million inhabitants and faces problems of overcrowding. It has capacity for 16 beds, but houses 32 patients. Even so, it is considered one of the models of good care practices in infarction.

The reality of many units across the country, however, is quite different. “Most still do not have the thrombolytic, the medication that will open the blood vessel. There is also an insecurity of doctors in using it”, explains cardiologist Camila Rocon, coordinator of the project at Hcor.

In a heart attack, the thrombolytic works in two ways: it helps dissolve the clots that are blocking the arteries, allowing blood to circulate throughout the body, and it also facilitates the repair and recovery of the affected heart muscle. The faster the medication is started, the greater the chances of reducing sequelae and preventing future complications.

Each vial of the drug costs around R$7,000. Depending on the patient, two vials are required. The high cost is one of the justifications for shortages in the UPAs.

According to Rodrigo Almeida, a cardiologist at BP, there is still uncertainty in its use. The medication thins the blood, with the risk of bleeding. There are contraindications in cases of uncontrolled blood pressure, recent history of bleeding, head trauma or recent stroke, among others.

“If we manage to guide the colleague so that he takes the medication safely, at the right time, we increase the survival of that patient and greatly reduce the costs for the health system”, he says.

Thirty of the UPAs assisted in the project have also received face-to-face visits from teams from partner hospitals. For example, the physical structure, the positioning of the electrocardiogram, the flow of the patient with chest pain and the average times of this journey are evaluated.

“In some places, we observed that the electrocardiogram was not included in the screening. The patient with chest pain had to walk through the corridors to undergo the exam”, says Camila.

There were situations in which the nurse had to wait for authorization from the physician to perform the electrocardiogram. “We suggested, and they accepted, giving the nursing team more autonomy to run the electro when detecting chest pain. It already saves time.”

The project has helped to reorganize the flow of patients within the UPAs and also trained doormen and receptionists to recognize patients with infarction symptoms. “In many situations, the patient had chest pain, pale, sweating, sitting in the waiting room, just like other people. Now, questions are asked and he goes ahead”, explains Rodrigo Almeida.

Another major challenge has been the high turnover of physicians in the UPAs, which hinders the training of these professionals. “You do the virtual training, engage and, in a little while, change the entire range of professionals. It is an anguish for us and for the managers”, reports Camila.

The project also operates in the cardiology emergency department of 30 public hospitals. It monitors, for example, the time in which a heart attack patient arrives at the hospital and undergoes a catheterization. The survey showed that there was a 25% reduction in this time in 15 hospital institutions, from 80 to 60 minutes. The target is 90 minutes.

In 15 of the UPAs that undergo training in good practices, a 58% decrease in cardiovascular mortality was recorded in relation to the rest, but the overall impact on deaths is still being evaluated because it depends on factors related to access to hospitals for procedures such as catheterization and angioplasty .

“He will need the catheterization, to find out what the injury is and if there are others, and to have a definitive treatment strategy. But, if we don’t act in the beginning, this patient will be even more harmed”, says the doctor.

In a note, the Ministry of Health says that it is a priority to guarantee faster access to surgeries, exams and consultations in the SUS, within the National Program for Reducing Queues, which also includes heart attack treatments. The total investment in 2023 will be R$ 600 million.

The ministry also states that it will strengthen strategic actions for the care of patients diagnosed with a heart attack, such as readjusting the amounts paid for thrombolytic drugs (alteplase and tenecteplase).