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Using uniform stickers on instant messaging apps shortens the time to feedback on prehospital ECGs

  • Author Footnotes
    1 Yung-Hua Chou and Ching-Hui Liao contributed equally.
    Yung-Hua Chou
    Footnotes
    1 Yung-Hua Chou and Ching-Hui Liao contributed equally.
    Affiliations
    Fire Bureau of Changhua County Government, Changhua, Taiwan

    National Changhua University of Education, Changhua, Taiwan
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  • Author Footnotes
    1 Yung-Hua Chou and Ching-Hui Liao contributed equally.
    Ching-Hui Liao
    Footnotes
    1 Yung-Hua Chou and Ching-Hui Liao contributed equally.
    Affiliations
    Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan
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  • Chien-Wei Tseng
    Affiliations
    Fire Bureau of Changhua County Government, Changhua, Taiwan
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  • Chi-Hung Lin
    Affiliations
    Fire Bureau of Changhua County Government, Changhua, Taiwan
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  • Chih-yuan Yang
    Affiliations
    Fire Bureau of Changhua County Government, Changhua, Taiwan
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  • Shang-Yan Yu
    Affiliations
    Fire Bureau of Changhua County Government, Changhua, Taiwan
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  • Chi Hsien Lin
    Affiliations
    Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan
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  • Chu-Chung Chou
    Affiliations
    Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan

    Chung Shan Medical University, School of Medicine, Taichung, Taiwan

    Kaohsiung Medical University, School of Medicine, Kaohsiung, Taiwan
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  • Yuan-Po Yang
    Affiliations
    Department of Cardiology, Changhua Christian Hospital, Changhua, Taiwan

    PhD Program in Tissue Engineering and Regenerative Medicine, National Chung-Hsing University and National Health Research Institutes, Taichung, Taiwan

    Institute of Biomedical Engineering and Nanomedicine, National Health Research Institutes, Zhunan Miaoli, Taiwan
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  • Yan-Ren Lin
    Correspondence
    Corresponding author at: Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, 135 Nanshsiao Street, Changhua 500, Taiwan.
    Affiliations
    Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan

    Chung Shan Medical University, School of Medicine, Taichung, Taiwan

    Kaohsiung Medical University, School of Medicine, Kaohsiung, Taiwan
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  • Author Footnotes
    1 Yung-Hua Chou and Ching-Hui Liao contributed equally.
      To the Editor,
      Although the benefits of prehospital ECG have been clearly demonstrated, only a few studies have focused on the challenges of data transmission/interpretation.
      • Al-Zaiti S.S.
      • Shusterman V.
      • Carey M.G.
      • et al.
      Novel technical solutions for wireless ECG transmission & analysis in the age of the internet cloud.
      Instant messaging apps (i.e., LINE@, WhatsApp@) have not been adequately leveraged to improve the transmission/interpretation of prehospital ECGs.
      During the study period (January 1, 2018 to December 31, 2019), our local government and regional hospitals sought to establish a solution that would prevent delays and errors in prehospital ECG transmission/interpretation. First, we established a 24-h chat group using an instant messaging app (LINE@). The members (n = 182) of this chat group included local emergency department (ED) physicians, cardiologists, and EMS personnel. Second, the prehospital ECG (as a deidentified PDF file) could be uploaded immediately to the chat group by EMS personnel using 12-lead ECG machines with Internet of Things functionality. Finally, in this chat group, the styles of feedback were not limited, and free text and uniform text/stickers (only mentioning “ST elevation” or “no ST elevation”) were all allowable (Fig. 1).
      Fig. 1
      Fig. 1The prehospital ECG could be performed at the scene or in the ambulance. Data could be uploaded directly to the LINE@ chat group with an IoT device (SIM card with a 3G/4G signal). The feedback on prehospital ECG could be achieved by online physicians sending uniform text or stickers. The prehospital ECG could be opened as a PDF file (which could be zoomed in or out) on a smartphone. Uniform text indicates that online physicians had to type words, such as “ST elevation” or “no ST elevation”, in their feedback.
      During this period, 165 patients’ prehospital ECGs (patients with severe chest pain) were uploaded to this LINE@ chat group, and all of them were reviewed and assessed by ED physicians or cardiologists. Among the 165 patients, 26 (15.8%) were diagnosed with STEMI and received emergency PCI in the ED (study group). To analyze the effects of prehospital ECGs on delays and outcomes, we matched two another comparison groups and adjusting variables with study group (group A: EMS without prehospital ECG, n = 52; group B: non-EMS patients, n = 52, each of them were diagnosed as STEMI and received PCI in ED). Of all, we found that prehospital ECGs did not significantly increase the time from the scene to the hospital; however, they significantly decreased “Triage time” “DTB time” “Door-to-first-ED ECG time” “Door-to-completed dual antiplatelet therapy (DAPT) time” and “The durations of ED and ICU stays”.
      The “time to first response” was much shorter when using LINE@ than when using email. In addition, sending LINE@ uniform stickers cost less time than sending free or uniform text. We also noticed that physicians were more likely to respond and to respond quickly when feedback could be provided by sending uniform stickers.
      In conclusion, instant messaging apps effectively shortened the time to first feedback on prehospital ECGs from online physicians. More importantly, physicians were more likely to respond and to respond quickly when feedback could be achieved by sending uniform stickers.

      Conflict of interest

      None declared.

      Funding

      None.

      Acknowledgements

      We would like to thank Changhua County Government and all members in this chat group for contributed greatly to establishing the response system.

      Reference

        • Al-Zaiti S.S.
        • Shusterman V.
        • Carey M.G.
        • et al.
        Novel technical solutions for wireless ECG transmission & analysis in the age of the internet cloud.
        J Electrocardiol. 2013; 46: 540-545