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. 2010 Jun;9(2):53-64.
doi: 10.1097/POC.0b013e3181d9d45c.

Emergency Cardiac Biomarkers and Point-of-Care Testing: Optimizing Acute Coronary Syndrome Care Using Small-World Networks In Rural Settings

Gerald J Kost  1 , Laurie E Kost, Audhaiwan Suwanyangyuen, Simrin K Cheema, Corbin Curtis, Stephanie Sumner, Jimmy Yu, Richard Louie
Affiliations

Emergency Cardiac Biomarkers and Point-of-Care Testing: Optimizing Acute Coronary Syndrome Care Using Small-World Networks In Rural Settings

Gerald J Kost et al. Point Care. 2010 Jun.
No abstract available

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Figures

Figure 1
Figure 1. Characterizing, Linking, and Integrating Small-World Networks (SWN) with Heart and Referral Centers
Frame A illustrates how Emergency Medical System (EMS) personnel characterized regional networks for patient rescue by highlighting ambulance routes directly on a high quality roadmap. Frame B shows (in orange) the SWNs for Community Hospitals in Kalasin and Maha Sarakham Provinces. The green route transports referred patients directly to the Queen Sirikit Heart Center and other hospitals in Khon Kaen City. Transport from regional and community hospitals in the extremes of other provinces requires as long as four hours, and is prohibitive for acute care. Helicopter rescue is not available. “Hybrid” transportation routes (pink) evolve to link SWNs and referral centers where cardiologists provide interventional therapy. Because of limited resources, cardiologists generally are not assigned to provincial regional hospitals. Thus, care paths need to focus on local SWNs and their integration.
Figure 2
Figure 2. Handheld Cardiac Biomarker Testing in Isaan—cTnT
We encountered the Cobas h 232 (cTnT, Roche Diagnostics Thailand) in one community hospital (Somdet), one regional hospital (Nong Khai), and the Heart Center in Khon Kaen (see Table 4). This ergonomic handheld device is being implemented aggressively throughout the country, including sites within these regions of Isaan since we conducted the survey, but is not yet licensed for diagnostic use in the United States. The i-STAT (not shown; Abbott) has the potential for cTnI testing, but in the Nong Khai Regional Hospital (the only location we encountered it), was used for blood gases and pH measurements in the ICU. [Photo by author (GK) on site at Nong Khai.]
Figure 3
Figure 3. Topographic SWN along the Mekong River—Nong Khai Province
This northern most province in Isaan borders the Mekong River and gateways Laos via a bridge to the capitol city of Vientiane on the other side of the Mekong River opposite Nong Khai, the namesake principal city. A sinuous long topography encourages low-income Laotians to cross the Mekong by any means available to seek medical assistance for acute and chronic problems in Nong Khai, but they cannot pay, thereby burdening already scant health resources. Newly initiated telemedicine in this province will augment animai (small clinics—triangles), but anamais operate during the day and generally do not have POCT.
Figure 4
Figure 4. Partnering Provinces—Sakon Nakhon and Nakhon Phanom SWN
This SWN provides healthcare services for Sakon Nakhon and the adjacent province, Nakhon Phanom, located to the northeast along the Mekong River and Laos. Travel to Khon Kaen would require helicopter transport, but virtually none, except rare private or military transport, is available, and when available, typically fly wealthy patients directly to specialty tertiary care centers in Bangkok. Some animai (triangles) have telehealth capability.
Figure 5
Figure 5. Demographic Distribution of Healthcare Resources
Overly burdened general practitioners and nurses lack support of specialists within Isaan SWNs where cardiologists, intensivists, and emergency medicine physicians are badly needed, especially for acute coronary syndrome (ACS), cardiac catheterization, and percutaneous intervention (PCI) in provincial regional hospitals.
Figure 6
Figure 6. Value Proposition for POC Cardiac Biomarker Testing in SWN ERs
Rapid therapeutic turnaround time (TTAT) adds value, but requires an integrated approach that encompasses the entire healthcare delivery system, that is, the SWN in order to generate fast treatment decisions for value synthesis. If not efficient (pathway to the right), traditional laboratory testing may introduce lengthy confounding processing delays for the diagnosis of ACS and AMI patients, for whom time to treatment and diagnosis are of the essence.
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References

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