Telemedical support for prehospital emergency medical service in severe emergencies: an open-label randomised non-inferiority clinical trial.

BACKGROUND: A tele-emergency medical service with a remote emergency physician for severe prehospital emergencies may overcome the increasing number of emergency calls and shortage of emergency medical service providers. We analysed whether routine use of a tele-emergency medical service is non-inferior to a conventional physician-based one in the occurrence of intervention-related adverse events. METHODS: This open-label, randomised, controlled, parallel-group, non-inferiority trial included all routine severe emergency patients aged ≥ 18 years within the ground-based ambulance service of Aachen, Germany. Patients were randomised in a 1:1 allocation ratio to receive either tele-emergency medical service (n = 1764) or conventional physician-based emergency medical service (n = 1767). The primary outcome was the occurrence of intervention-related adverse events with suspected causality to the group assignment. The trial was registered with ClinicalTrials.gov (NCT02617875) on 30 November 2015 and is reported in accordance with the CONSORT statement for non-inferiority trials. RESULTS: Among 3531 randomised patients, 3220 were included in the primary analysis (mean age, 61.3 years; 53.8% female); 1676 were randomised to the conventional physician-based emergency medical service (control) group and 1544 to the tele-emergency medical service group. A physician was not deemed necessary in 108 of 1676 cases (6.4%) and 893 of 1544 cases (57.8%) in the control and tele-emergency medical service groups, respectively. The primary endpoint occurred only once in the tele-emergency medical service group. The Newcombe hybrid score method confirmed the non-inferiority of the tele-emergency medical service, as the non-inferiority margin of - 0.015 was not covered by the 97.5% confidence interval of - 0.0046 to 0.0025. CONCLUSIONS: Among severe emergency cases, tele-emergency medical service was non-inferior to conventional physician-based emergency medical service in terms of the occurrence of adverse events.

[Evaluation of the project for the introduction of bystander resuscitation in schools in North Rhine-Westphalia]. / Evaluation des Projekts zur Einführung von Laienreanimation an Schulen in Nordrhein-Westfalen.

BACKGROUND: Teaching of resuscitation measures is not mandatory in all schools in Germany. It is currently limited to individual, partly mandatory projects despite a low bystander resuscitation rate. For this reason, the Ministry for Schools and Education of North Rhine-Westphalia initiated the project "Bystander resuscitation at schools in NRW" in March 2017. OBJECTIVE: The aim of this work was to evaluate this project. MATERIAL AND METHODS: All secondary schools in North Rhine-Westphalia were invited to participate in the project. Medical partners from each administrative district took part, who carried out resuscitation training with existing concepts for teacher or student training. After a 3-year period, the evaluation was carried out using standardized questionnaires for school headmasters, teachers and students. RESULTS: In total, more than 40,000 pupils from 249 schools in NRW could be trained in resuscitation within the project with 6 different concepts. Of the students 85% answered the questions regarding resuscitation correctly and overall felt safe in resuscitation measures. The one-off investment requirement for all schools is roughly 4-6.5 million € and around 340,000 € in each budget year. CONCLUSION: A legal constitution and funding are necessary for a nationwide introduction of resuscitation in schools. All established concepts are effective, therefore each school can use them exactly according to their needs, optimally in a stepped form. Training for teachers should focus on resuscitation.

Utilization, Safety, and Technical Performance of a Telemedicine System for Prehospital Emergency Care: Observational Study.

BACKGROUND: As a consequence of increasing emergency medical service (EMS) missions requiring an EMS physician on site, we had implemented a unique prehospital telemedical emergency service as a new structural component to the conventional physician-based EMS in Germany. OBJECTIVE: We sought to assess the utilization, safety, and technical performance of this telemedical emergency service. METHODS: We conducted a retrospective analysis of all primary emergency missions with telemedical consultation of an EMS physician in the City of Aachen (250,000 inhabitants) during the first 3 operational years of our tele-EMS system. Main outcome measures were the number of teleconsultations, number of complications, and number of transmission malfunctions during teleconsultations. RESULTS: The data of 6265 patients were analyzed. The number of teleconsultations increased during the run-in period of four quarters toward full routine operation from 152 to 420 missions per quarter. When fully operational, around the clock, and providing teleconsultations to 11 mobile ambulances, the number of teleconsultations further increased by 25.9 per quarter (95% CI 9.1-42.6; P=.009). Only 6 of 6265 patients (0.10%; 95% CI 0.04%-0.21%) experienced adverse events, all of them not inherent in the system of teleconsultations. Technical malfunctions of single transmission components occurred from as low as 0.3% (95% CI 0.2%-0.5%) during two-way voice communications to as high as 1.9% (95% CI 1.6%-2.3%) during real-time vital data transmissions. Complete system failures occurred in only 0.3% (95% CI 0.2%-0.6%) of all teleconsultations. CONCLUSIONS: The Aachen prehospital EMS is a frequently used, safe, and technically reliable system to provide medical care for emergency patients without an EMS physician physically present. Noninferiority of the tele-EMS physician compared with an on-site EMS physician needs to be demonstrated in a randomized trial.

Telemedizin: Potenziale in der Notfallmedizin.

The telemedical support and networking between health personnel and medical specialists increases the quality of supply also in the prehospital emergency care. Till now only for some tracer diagnosis specifically designed telemedical services were used. However, now a unique holistic telemedicine system, which can be used for the whole emergency spectrum as a supplementary feature has been developed. It can be used for the whole prehospital emergency care. The needfulness and meaningfulness of telemedicine as well as the important structural characteristics in prehospital emergency care are pictured. The system, composed of hard- and software components (tele-physician working place, server infrastructure, mobile and in the ambulance fixed transmission box), ensures the availability of secure data transfer of speech, vital-parameters, photos, videostream, 12 lead ECG, etc.) in real-time. Base for a safe telemedicine application are the guidelines of the German Association of Anaesthesiology. Telemedicine systems are usable in different indications and disease manifestations. However, telemedicine also has limitations. Conclusion Telemedically assisted emergency missions can be managed safely, achieve a better quality in documentation and guideline conform therapy, reduce the medical binding time about more than 50 %, reduce physician escorting missions and show at least an equivalent quality of supply.

Acute and sustained effects of methylphenidate on cognition and presynaptic dopamine metabolism: an [18F]FDOPA PET study.

Methylphenidate (MPH) inhibits the reuptake of dopamine and noradrenaline. PET studies with MPH challenge show increased competition at postsynaptic D2/3-receptors, thus indirectly revealing presynaptic dopamine release. We used [(18)F]fluorodopamine ([(18)F]FDOPA)-PET in conjunction with the inlet-outlet model (IOM) of Kumakura et al. (2007) to investigate acute and long-term changes in dopamine synthesis capacity and turnover in nigrostriatal fibers of healthy subjects with MPH challenge. Twenty healthy human females underwent two dynamic [(18)F]FDOPA PET scans (124 min; slow bolus-injection; arterial blood sampling), with one scan in untreated baseline condition and the other after MPH administration (0.5 mg/kg, p.o.), in randomized order. Subjects underwent cognitive testing at each PET session. Time activity curves were obtained for ventral putamen and caudate and were analyzed according to the IOM to obtain the regional net-uptake of [(18)F]FDOPA (K; dopamine synthesis capacity) as well as the [(18)F]fluorodopamine washout rate (kloss, index of dopamine turnover). MPH substantially decreased kloss in putamen (-22%; p = 0.003). In the reversed treatment order group (MPH/no drug), K was increased by 18% at no drug follow-up. The magnitude of K at the no drug baseline correlated with cognitive parameters. Furthermore, individual kloss changes correlated with altered cognitive performance under MPH. [(18)F]FDOPA PET in combination with the IOM detects an MPH-evoked decrease in striatal dopamine turnover, in accordance with the known acute pharmacodynamics of MPH. Furthermore, the scan-ordering effect on K suggested that a single MPH challenge persistently increased striatal dopamine synthesis capacity. Attenuation of dopamine turnover by MPH is linked to enhanced cognitive performance in healthy females.

Smartphone apps for cardiopulmonary resuscitation training and real incident support: a mixed-methods evaluation study.

BACKGROUND: No systematic evaluation of smartphone/mobile apps for resuscitation training and real incident support is available to date. To provide medical, usability, and additional quality criteria for the development of apps, we conducted a mixed-methods sequential evaluation combining the perspective of medical experts and end-users. OBJECTIVE: The study aims to assess the quality of current mobile apps for cardiopulmonary resuscitation (CPR) training and real incident support from expert as well as end-user perspective. METHODS: Two independent medical experts evaluated the medical content of CPR apps from the Google Play store and the Apple App store. The evaluation was based on pre-defined minimum medical content requirements according to current Basic Life Support (BLS) guidelines. In a second phase, non-medical end-users tested usability and appeal of the apps that had at least met the minimum requirements. Usability was assessed with the System Usability Scale (SUS); appeal was measured with the self-developed ReactionDeck toolkit. RESULTS: Out of 61 apps, 46 were included in the experts' evaluation. A consolidated list of 13 apps resulted for the following layperson evaluation. The interrater reliability was substantial (kappa=.61). Layperson end-users (n=14) had a high interrater reliability (intraclass correlation 1 [ICC1]=.83, P<.001, 95% CI 0.75-0.882 and ICC2=.79, P<.001, 95% CI 0.695-0.869). Their evaluation resulted in a list of 5 recommendable apps. CONCLUSIONS: Although several apps for resuscitation training and real incident support are available, very few are designed according to current BLS guidelines and offer an acceptable level of usability and hedonic quality for laypersons. The results of this study are intended to optimize the development of CPR mobile apps. The app ranking supports the informed selection of mobile apps for training situations and CPR campaigns as well as for real incident support.

Prehospital emergency anesthesia: A single-center retrospective analysis of guideline adherence and unexpected incidents.

Although prehospital emergency anesthesia (PHEA), with a specific focus on intubation attempts, is frequently studied in prehospital emergency care, there is a gap in the knowledge on aspects related to adherence to PHEA guidelines. This study investigates adherence to the "Guidelines for Prehospital Emergency Anesthesia in Adults" with regard to the induction of PHEA, including the decision making, rapid sequence induction, preoxygenation, standard monitoring, intubation attempts, adverse events, and administration of appropriate medications and their side effects. This retrospective study examined PHEA interventions from 01/01/2020 to 12/31/2021 in the city of Aachen, Germany. The inclusion criteria were adult patients who met the indication criteria for the PHEA. Data were obtained from emergency medical protocols. A total of 127 patients were included in this study. All the patients met the PHEA indication criteria. Despite having a valid indication, 29 patients did not receive the PHEA. 98 patients were endotracheally intubated. For these patients, monitoring had conformed to the guidelines. The medications were used according to the guidelines. A significant increase in oxygen saturation was reported after anesthesia induction (p < 0.001). The patients were successfully intubated endotracheally on the third attempt. Guideline adherence was maintained in terms of execution of PHEA, rapid sequence induction, preoxygenation, monitoring, selection, and administration of relevant medications. Emergency physicians demonstrated the capacity to effectively respond to cardiorespiratory events. Further investigations are needed on the group of patients who did not receive PHEA despite meeting the criteria. The underlying causes of decision making in these cases need to be evaluated in the future.

Long-term effects of a prehospital telemedicine system on structural and process quality indicators of an emergency medical service.

The benefits of a telemedical support system for prehospital emergency medical services include high-level emergency medical support at the push of a button: delegation of drug administration, diagnostic assistance, initiation of therapeutic measures, or choice of hospital destination. At various European EMS sites telemedical routine systems are shortly before implementation. The aim of this study was to investigate the long-term effects of implementing a tele-EMS system on the structural and procedural quality indicators and therefore performance of an entire EMS system. This retrospective study included all EMS missions in Aachen city between 2015 and 2021. Regarding structural indicators of the EMS system, we investigated the overall number of emergency missions with tele-EMS and onsite EMS physicians. Furthermore, we analyzed the distribution of tracer diagnosis and process quality with respect to the time spans on the scene, time until teleconsultation, duration of teleconsultation, prehospital engagement time, and number of simultaneous teleconsultations. During the 7-year study period, 229,384 EMS missions were completed. From 2015 to 2021, the total number of EMS missions increased by 8.5%. A tele-EMS physician was consulted on 23,172 (10.1%) missions. The proportion of telemedicine missions increased from 8.6% in 2015 to 12.9% in 2021. Teleconsultations for missions with tracer diagnoses decreased during from 43.7% to 30.7%, and the proportion of non-tracer diagnoses increased from 56.3% to 69.3%. The call duration for teleconsultation decreased from 12.07 min in 2015 to 9.42 min in 2021. For every fourth mission, one or more simultaneous teleconsultations were conducted by the tele-EMS physician on duty. The implementation and routine use of a tele-EMS system increased the availability of onsite EMS physicians and enabled immediate onsite support for paramedics. Parallel teleconsultations, reduction in call duration, and increase in ambulatory onsite treatments over the years demonstrate the increasing experience of paramedics and tele-EMS physicians with the system in place. A prehospital tele-EMS system is important for mitigating the current challenges in the prehospital emergency care sector.

Remote ischaemic preconditioning for heart surgery. The study design for a multi-center randomized double-blinded controlled clinical trial--the RIPHeart-Study.

AIMS: Transient ischaemia of non-vital tissue has been shown to enhance the tolerance of remote organs to cope with a subsequent prolonged ischaemic event in a number of clinical conditions, a phenomenon known as remote ischaemic preconditioning (RIPC). However, there remains uncertainty about the efficacy of RIPC in patients undergoing cardiac surgery. The purpose of this report is to describe the design and methods used in the "Remote Ischaemic Preconditioning for Heart Surgery (RIPHeart)-Study". METHODS: We are conducting a prospective, randomized, double-blind, multicentre, controlled trial including 2070 adult cardiac surgical patients. All types of surgery in which cardiopulmonary bypass is used will be included. Patients will be randomized either to the RIPC group receiving four 5 min cycles of transient upper limb ischaemia/reperfusion or to the control group receiving four cycles of blood pressure cuff inflation/deflation at a dummy arm. The primary endpoint is a composite outcome (all-cause mortality, non-fatal myocardial infarction, any new stroke, and/or acute renal failure) until hospital discharge. CONCLUSION: The RIPHeart-Study is a multicentre trial to determine whether RIPC may improve clinical outcome in cardiac surgical patients.

[Update tele-emergency medicine : Status quo and perspectives]. / Update Telenotfallmedizin : Status quo und Ausblick.

CURRENT STATUS OF EMERGENCY MEDICINE IN GERMANY: Increasing numbers of rescue missions in recent years have led to a growing staff shortage of paramedics as well as physicians in the emergency medical system (EMS) with an urgent need for optimized usage of resources. One option is the implementation of a tele-EMS physician system, which has been established in the EMS of the City of Aachen since 2014. IMPLEMENTATION OF TELE-EMERGENCY MEDICINE: In addition to pilot projects, political decisions lead to the introduction of tele-emergency medicine. The expansion is currently progressing in various federal states, and a comprehensive introduction has been decided for North Rhine-Westphalia and Bavaria. The adaptation of the EMS physician catalog of indications is essential for the integration of a tele-EMS physician. STATUS QUO OF TELE-EMERGENCY MEDICINE: The tele-EMS physician offers the possibility of a long-term and comprehensive EMS physician expertise in the EMS regardless of location and, therefore, to partially compensate for a lack of EMS physicians. Tele-EMS physicians can also support the dispatch center in an advisory capacity and, for example, clarify secondary transport. A uniform qualification curriculum for tele-EMS physicians was introduced by the North Rhine and Westphalia-Lippe Medical Associations. OUTLOOK: In addition to consultations from emergency missions, tele-emergency medicine can also be used for innovative educational applications, for example, in the supervision of young physicians or recertification of EMS staff. A lack of ambulances could be compensated for by a community emergency paramedic, who could also be connected to the tele-EMS physician.

Immobilization in Emergency Medical Service - Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians.

Background: The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device. Methods: A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter. Results: Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard. Conclusion: It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.

Shedding light into the black box of out-of-hospital respiratory distress-A retrospective cohort analysis of discharge diagnoses, prehospital diagnostic accuracy, and predictors of mortality.

BACKGROUND: Although respiratory distress is one of the most common complaints of patients requiring emergency medical services (EMS), there is a lack of evidence on important aspects. OBJECTIVES: Our study aims to determine the accuracy of EMS physician diagnostics in the out-of-hospital setting, identify examination findings that correlate with diagnoses, investigate hospital mortality, and identify mortality-associated predictors. METHODS: This retrospective observational study examined EMS encounters between December 2015 and May 2016 in the city of Aachen, Germany, in which an EMS physician was present at the scene. Adult patients were included if the EMS physician initially detected dyspnea, low oxygen saturation, or pathological auscultation findings at the scene (n = 719). The analyses were performed by linking out-of-hospital data to hospital records and using binary logistic regressions. RESULTS: The overall diagnostic accuracy was 69.9% (485/694). The highest diagnostic accuracies were observed in asthma (15/15; 100%), hypertensive crisis (28/33; 84.4%), and COPD exacerbation (114/138; 82.6%), lowest accuracies were observed in pneumonia (70/142; 49.3%), pulmonary embolism (8/18; 44.4%), and urinary tract infection (14/35; 40%). The overall hospital mortality rate was 13.8% (99/719). The highest hospital mortality rates were seen in pneumonia (44/142; 31%) and urinary tract infection (7/35; 20%). Identified risk factors for hospital mortality were metabolic acidosis in the initial blood gas analysis (odds ratio (OR) 11.84), the diagnosis of pneumonia (OR 3.22) reduced vigilance (OR 2.58), low oxygen saturation (OR 2.23), and increasing age (OR 1.03 by 1 year increase). CONCLUSIONS: Our data highlight the diagnostic uncertainties and high mortality in out-of-hospital emergency patients presenting with respiratory distress. Pneumonia was the most common and most frequently misdiagnosed cause and showed highest hospital mortality. The identified predictors could contribute to an early detection of patients at risk.

[Quality of documentation and treatment in the non-physician staffed ambulance: a retrospective analysis of emergency protocols from the city of Aachen]. / Dokumentations- und Behandlungsqualität im Rettungsdienst: eine retrospektive Analyse von Einsatzprotokollen in der Stadt Aachen.

BACKGROUND: Each year there are 7.3 million emergencies for the German rescue service, trend rising and around 59% of the emergency patients are treated by paramedics only; however, most of the studies focus on physicians, while their practical skills at the scene are rarely necessary. Accordingly, the responsibility for the patient lies with the paramedics most of the time. Their duty is to execute life-saving measures, stabilize the patient for the transport and the regular documentation of the operation. Retrospectively, the emergencies can only be analyzed based on the emergency protocols, which are mostly paper-based and handwritten. That causes an increased effort in the evaluation, which makes studies for the whole country hardly feasible. As of now there are only few data on quality of healthcare and documentation by the paramedics. Both were analyzed in this survey based on the emergency protocols. METHOD: A retrospective analysis of emergency protocols from June to July 2018 took place in Aachen, a major German city. A specific feature of Aachen is a 24­h available emergency physician via telemedicine. The quality of documentation and healthcare was analyzed by including standard operating procedures. Primary endpoints were the frequency of documentation, the achievement of complete documentation, the correct indications for a physician, the development of critical vital signs and the average on-scene time of the ambulance. RESULTS: Overall, 1935 protocols were analyzed. A complete documentation was achieved in 1323 (68.4%) suspected diagnoses, 456 (23.6%) anamneses, 350 (18.1%) initial and 52 (2.7%) vital signs at handover. Based on the documentation, there were 531 cases (27%) of patients treated by paramedics only, even though a physician would have been indicated. Out of those patients 410 critical initial vital signs were documented of which 69 (16.8%) improved, while there was no documentation of vital signs at handover in 217 (52.9%). Also, there was a significantly prolonged on-scene time for patients with belated indications for an emergency physician with 15:02 min in comparison to 13:05 min for patients without indications. CONCLUSION: Deficient documentation was found in multiple cases and several important vital signs for a complete differential diagnosis were missing. Furthermore, a quarter of all patients might have benefited from an emergency physician as they were taken to hospital with no or insufficient treatment, despite standard operating procedures. From a forensic point of view there is an alarmingly incomplete documentation of vital signs at handover. The on-scene time in general was within the predetermined time frame, but can still be reduced in different scenarios. Overall, we recommend strict adherence to the standard operating procedures and algorithms, to remove unnecessary documentation and implement a structured quality assurance. Moreover, the quality of treatment might benefit from the rising number of more specialized paramedics and an increasing use of telemedicine.

Augmented Reality for Guideline Presentation in Medicine: Randomized Crossover Simulation Trial for Technically Assisted Decision-making.

BACKGROUND: Guidelines provide instructions for diagnostics and therapy in modern medicine. Various mobile devices are used to represent the potential complex decision trees. An example of time-critical decisions is triage in case of a mass casualty incident. OBJECTIVE: In this randomized controlled crossover study, the potential of augmented reality for guideline presentation was evaluated and compared with the guideline presentation provided in a tablet PC as a conventional device. METHODS: A specific Android app was designed for use with smart glasses and a tablet PC for the presentation of a triage algorithm as an example for a complex guideline. Forty volunteers simulated a triage based on 30 fictional patient descriptions, each with technical support from smart glasses and a tablet PC in a crossover trial design. The time to come to a decision and the accuracy were recorded and compared between both devices. RESULTS: A total of 2400 assessments were performed by the 40 volunteers. A significantly faster time to triage was achieved in total with the tablet PC (median 12.8 seconds, IQR 9.4-17.7; 95% CI 14.1-14.9) compared to that to triage with smart glasses (median 17.5 seconds, IQR 13.2-22.8, 95% CI 18.4-19.2; P=.001). Considering the difference in the triage time between both devices, the additional time needed with the smart glasses could be reduced significantly in the course of assessments (21.5 seconds, IQR 16.5-27.3, 95% CI 21.6-23.2) in the first run, 17.4 seconds (IQR 13-22.4, 95% CI 17.6-18.9) in the second run, and 14.9 seconds (IQR 11.7-18.6, 95% CI 15.2-16.3) in the third run (P=.001). With regard to the accuracy of the guideline decisions, there was no significant difference between both the devices. CONCLUSIONS: The presentation of a guideline on a tablet PC as well as through augmented reality achieved good results. The implementation with smart glasses took more time owing to their more complex operating concept but could be accelerated in the course of the study after adaptation. Especially in a non-time-critical working area where hands-free interfaces are useful, a guideline presentation with augmented reality can be of great use during clinical management.

Implementation of a full-scale prehospital telemedicine system: evaluation of the process and systemic effects in a pre-post intervention study.

OBJECTIVES: To review the implementation strategy from a research project towards routine care of a comprehensive mobile physician-staffed prehospital telemedicine system. The objective is to evaluate the implementation process and systemic influences on emergency medical service (EMS) resource utilisation. DESIGN: Retrospective pre-post implementation study. SETTING: Two interdisciplinary projects and the EMS of a German urban region. INTERVENTIONS: Implementation of a full-scale prehospital telemedicine system. ENDPOINTS: Descriptive evaluation of the implementation strategy. Primary endpoint: ground-based and helicopter-based physician staffed emergency missions before and after implementation. RESULTS: The first research project revealed positive effects on guideline adherence and patient safety in two simulation studies, with feasibility demonstrated in a clinical study. After technical optimisation, safety and positive effects were demonstrated in a multicentre trial. Routine care in the city of Aachen, Germany was conducted stepwise from April 2014 to March 2015, including modified dispatch criteria. Systemic parameters of all EMS assignments between pre-implementation (April 2013 to March 2014) and post implementation (April 2015 to March 2016): on-scene EMS physician operations decreased from 7882/25 187 missions (31.3%) to 6360/26 462 (24.0%), p<0.0001. The need for neighbouring physician-staffed units dropped from 234/25 187 (0.93%) to 119/26 462 (0.45%), p<0.0001, and the need for helicopter EMS from 198/25 187 (0.79%) to 100/26 462 (0.38%), p<0.0001. In the post implementation period 2347 telemedical interventions were conducted, with 26 462 emergency missions (8.87%). CONCLUSION: A stepwise implementation strategy allowed transfer from the project phase to routine care. We detected a reduced need for conventional on-scene physician care by ground-based and helicopter-based EMS, but cannot exclude unrecognised confounders, including modified dispatch criteria and possible learning effects. This creates the potential for increased availability of EMS physicians for life-threatening emergencies by shifting physician interventions from conventional to telemedical care. TRIAL REGISTRATION NUMBER: NCT04127565.

Tele-EMS physicians improve life-threatening conditions during prehospital emergency missions.

Almost seven years ago, a telemedicine system was established as an additional component of the city of Aachen's emergency medical service (EMS). It allows paramedics to engage in an immediate consultation with an EMS physician at any time. The system is not meant to replace the EMS physician on the scene during life-threatening emergencies. The aim of this study was to analyze teleconsultations during life-threatening missions and evaluate whether they improve patient care. Telemedical EMS (tele-EMS) physician consultations that occurred over the course of four years were evaluated. Missions were classified as involving potentially life-threatening conditions based on at least one of the following criteria: documented patient severity score, life-threatening vital signs, the judgement of the onsite EMS physician involved in the mission, or definite life-threatening diagnoses. The proportion of vital signs indicating that the patient was in a life-threatening condition was analyzed as the primary outcome at the start and end of the tele-EMS consultation. The secondary outcome parameters were the administered drug doses, tracer diagnoses made by the onsite EMS physicians during the missions, and quality of the documentation of the missions. From January 2015 to December 2018, a total of 10,362 tele-EMS consultations occurred; in 4,293 (41.4%) of the missions, the patient was initially in a potentially life-threatening condition. Out of those, a total of 3,441 (80.2%) missions were performed without an EMS physician at the scene. Records of 2,007 patients revealed 2,234 life-threatening vital signs of which 1,465 (65.6%) were remedied during the teleconsultation. Significant improvement was detected for oxygen saturation, hypotonia, tachy- and bradycardia, vigilance states, and hypoglycemia. Teleconsultation during missions involving patients with life-threatening conditions can significantly improve those patients' vital signs. Many potentially life-threatening cases could be handled by a tele-EMS physician as they did not require any invasive interventions that needed to be performed by an onsite EMS physician. Diagnoses of myocardial infarction, cardiac pulmonary edema, or malignant dysrhythmias necessitate the presence of onsite EMS physicians. Even during missions involving patients with life-threatening conditions, teleconsultation was feasible and often accessed by the paramedics.

Comparing the diagnostic concordance of tele-EMS and on-site-EMS physicians in emergency medical services: a retrospective cohort study.

In 2014, a telemedicine system was established in 24-h routine use in the emergency medical service (EMS) of the city of Aachen. This study tested whether the diagnostic concordance of the tele-EMS physician reaches the same diagnostic concordance as the on-site-EMS physician. The initial prehospital diagnoses were compared to the final hospital diagnoses. Data were recorded retrospectively from the physicians' protocols as well as from the hospital administration system and compared. Also, all diagnostic misconcordance were analysed and reviewed in terms of logical content by two experts. There were no significant differences between the groups in terms of demographic data, such as age and gender, as well as regarding the hospital length of stay and mortality. There was no significant difference between the diagnostic concordance of the systems, except the diagnosis "epileptic seizure". Instead, in these cases, "stroke" was the most frequently chosen diagnosis. The diagnostic misconcordance "stroke" is not associated with any risks to patients' safety. Reasons for diagnostic misconcordance could be the short contact time to the patient during the teleconsultation, the lack of personal examination of the patient by the tele-EMS physician, and reversible symptoms that can mask the correct diagnosis.

Improved technical performance of a multifunctional prehospital telemedicine system between the research phase and the routine use phase - an observational study.

Introduction Telemedical concepts in emergency medical services (EMS) lead to improved process times and patient outcomes, but their technical performance has thus far been insufficient; nevertheless, the concept was transferred into EMS routine care in Aachen, Germany. This study evaluated the system's technical performance and compared it to a precursor system. Methods The telemedicine system was implemented on seven ambulances and a teleconsultation centre staffed with experienced EMS physicians was established in April 2014. Telemedical applications included mobile vital data, 12-lead, picture transmission and video streaming from inside the ambulances. The tele-EMS physician filled in a questionnaire regarding the technical performance of the applications, background noise and assessed clinical values of the transmitted pictures and videos after each mission between 15 May 2014-15 October 2014. Results Teleconsultation was established during 539 emergency cases. In 83% of the cases ( n = 447), only the paramedics and the tele-EMS physician were involved. Transmission success rates ranged from 98% (audio connection) to 93% (12-lead electrocardiogram (ECG) transmission). All functionalities, except video transmission, were significantly better than the pilot project ( p < 0.05). Severe background noise was detected to a lesser extent ( p = 0.0004) and the clinical value of the pictures and videos were considered significantly more valuable. Discussion The multifunctional system is now sufficient for routine use and is the most reliable mobile emergency telemedicine system compared to other published projects. Dropouts were due to user errors and network coverage problems. These findings enable widespread use of this system in the future, reducing the critical time intervals until medical therapy is started.

Technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service - an observational study.

We evaluated the technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service (EMS) from the user's perspective. The telemedicine system was designed to transmit vital signs data and 12-lead-ECG data, send still pictures and allow voice communication and video transmission from an ambulance. The data were sent to a teleconsultation centre staffed with EMS physicians (tele-EMS physician). The system was used in 157 EMS missions. The applications were used successfully on 80% of missions for real-time vital signs transmission and on 97% for video transmission. The quality of the transmitted still images (n = 64) was: 23% excellent, 50% good, 17% moderate, 9% rather poor and 0% unusable. The quality of the video streaming (n = 36) was: 33% excellent, 56% good, 6% moderate, 6% rather poor and 0% unusable. The tele-EMS physician was able to assist the EMS team in several cases and provided the preliminary information for the hospital in nearly all missions. Use of the telemedical system in EMS is feasible and the quality of the transmitted images and video was satisfactory. However, technical reliability and availability need to be improved prior to routine use.