Tabulated Appraisal of Short List
The appraisal for each of the 3 options remaining in the short list is listed in the following tabulation. They are each examined in detailed with regards to their projected benefits, costs and risks involved.
The following is the results for Option 1.
Tabulated Appraisal List
- Advanced alert as above with transmission of clinical data and remote physician decision support via the Mobimed System to facilitate pre-hospital thrombolysis if the patient meets the pre-specified criteria/check-lists.(25, 29, 30)
- Reduction of call to hospital-door transit time and intra-hospital door to needle time leads to time saved which ranged from 33(29) minutes to 130 minutes.(27)
- Remote decision support is provided by the physician via real-time transmission of the ECG and communication(25) via the Mobimed System, which has EC accreditation under the Medical Device Directive, is modular in design and has in built support for future integration into Electronic Health Care Records Systems.
- New enhanced role for the paramedic crew with further specialised training.
- Improved patient outcome.
- Minimal extra cost as the service would utilises pre-existing organisational structures and skills of the paramedic crews.
- Rapid start-up time due to above. Pedley has quoted six months from principal agreement from all partied to rolling out of service.
- Funds available from the NHS Plan; which has committed £14 million pounds per year for three years for new ECG equipment, telemetry and communication equipments, training of front-line staff, thrombolytic drugs, research and audit.
There is further funding available from the NSF for Coronary Heart Disease and the New Opportunity fund.
- Minimised clinical risks with the use of nationally agreed check-lists for eligibility and contra-indication to treatment.
- Future integration of the mobile monitoring and tele-medical information systems into the NHS Spine and Electronic Health Care Records to form a truly seamless health care system.
- As detailed above, the main costs are due to upgrading the equipment in the ambulances as well as providing a receiving unit in the Coronary Care Unit in the hospital.
- Paramedic crews already have the basic skills to provide Advanced Life Support as well as give intravenous medication. However, they will require funding for advanced training in ECG interpretation and thrombolysis.
- The costs of thrombolytic drugs were traditionally borne by the CCU. With this model of care, the cost would now shift to the Ambulance Trust.
- Using the new fourth generation thrombolytic agent which can be given as a bolus injection would avoid any additional equipment cost like intravenous pumps.
- However, there is a substantial Budget Impact Cost in switching from one drug to another. Paramedics had previously been licensed to administer Streptokinase. However, this needs to be given as an infusion. This is not thought to be feasible in the mobile environment, especially when time and speed is of the essence.
The use of tenecteplase has been projected to result in an increase of almost three times the budget for Streptokinase.(39)
Despite this increase, the incremental cost effectiveness ratio for using Tenecteplase over Streptokinase is £8321. This is still thought to be cost effective as it is significantly less than the accepted benchmark of £31,500.
- A maintenance budget must be set aside to ensure that the equipment is always functioning as per design.
- The transmission of ECG and asynchronous messaging communication system depends on the availability of mobile network coverage. This may be variable in the rural areas and some studies have reported problems with this.(26, 35)
The arrival of affordable and ubiquitous satellite phone networks such as "Globalstar" may offer a solution to this problem.
The network is based on low-earth-orbit satellites which enables link-up with low-power mobile devices and a clear line of sight for connection without any special calibration or directional antennas. Charges are only applied when data is sent and can be pre-paid in advanced.
At any one time, there are three Globalstar satellites within the horizon to provide the service throughout UK.
The Mobimed System by Ortivus is a mobile patient monitoring and tele-medical informatics system. In addition to mobile communication standards such as GSM, GPRS and PTSN, it also has a built in satellite phone which can take advantage of satellite communications as a back up.
This capability is being studied by the European Space Agency in a project called SECoM (Satellite Enhanced Coverage of Mobimed).
- Although there is no difference in terms of the risks undertaken by the paramedics in their daily work with critically ill patients, the Ambulance Trusts are still vicariously liable for any complications with the pre-hospital thrombolysis.
The risks can be minimised by using a nationally agreed checklist for inclusion and contra-indications to pre-hospital thrombolysis.
Informed consent must also be taken and recorded as per protocol. All these data can then form the basis for continuing audit and research in order to maintain and improve clinical standards.
- Although the remote physician gives support via the telemedicine system, the final decision and responsibility to thrombolyse the patient lies with the paramedic. This is essential to avoid any ethical-legal ambiguity in the care of the patient while in transit.
- 14 September, 2014telemedicine and health informatics. With regards to the Mobimed system, the transmission of the data is encrypted and secure. The degree of security can be modified and strengthened if necessary.
- Prior to the research which are showing benefit with the concurrent use of thrombolysis and mechanical re-perfusion, the setting up of regional mechanical re-perfusion centres would have precluded the use of pre-hospital thrombolysis.
- The main side effect of thrombolysis is stroke, which leads to long term morbidity and need for rehabilitation. However this risk is small (<1%) but must be explained to the patient as part of the informed consent.
This risk is balanced by the expected reduction of the rates of Left Heart Failure with early thrombolysis, which would reduce the significant long-term morbidity associated with it
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17 May, 2017