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.

Treatment of Acute Coronary Syndrome by Telemedically Supported Paramedics Compared With Physician-Based Treatment: A Prospective, Interventional, Multicenter Trial.

BACKGROUND: Prehospital treatment of acute coronary syndrome (ACS) in German emergency medical services (EMSs) is reserved for EMS physicians due to legal issues. OBJECTIVE: The objective of this prospective, interventional, multicenter trial was to evaluate the quality of telemedically-delegated therapy and the possible complications in patients with ACS. METHODS: After approval by the ethics committee and trial registration, a one-year study phase was started in August 2012 with 5 ambulances, telemedically equipped and staffed with paramedics, in 4 German EMS districts. The paramedics could contact an EMS-physician-staffed telemedicine center. After initiation of an audio connection, real-time data transmission was automatically established. If required, 12-lead electrocardiogram (ECG) and still pictures could be sent. Video was streamed from inside each ambulance. All drugs, including opioids, were delegated to the paramedics based on standardized, predefined algorithms. To compare telemedically-delegated medication and treatment in ACS cases with regular EMS missions, a matched pair analysis with historical controls was performed. RESULTS: Teleconsultation was performed on 150 patients having a cardiovascular emergency. In 39 cases, teleconsultation was started due to suspected ACS. No case had a medical complication. Correct handling of 12-lead ECG was performed equally between the groups (study group, n=38 vs control group, n=39, P>.99). There were no differences in correct handling of intravenous administration of acetylsalicylic acid, heparin, or morphine between both the groups (study group vs control group): acetylsalicylic acid, n=31 vs n=33, P=.73; unfractionated heparin, n=34 vs n=33, P>.99; morphine, n=29 vs n=27, P=.50. The correct handling of oxygen administration was significantly higher in the study group (n=29 vs n=18, P=.007). CONCLUSIONS: Telemedical delegation of guideline conform medication and therapy by paramedics in patients with ACS and was found to be feasible and safe. The quality of guideline-adherent therapy was not significantly different in both the groups except for the correct administration of oxygen, which was significantly higher in the study group. TRIAL REGISTRATION: Clinicaltrials.gov NCT01644006; http://clinicaltrials.gov/ct2/show/NCT01644006 (Archived by WebCite at http://www.webcitation.org/6mPam3eDy).

Quality of analgesia in physician-operated telemedical prehospital emergency care is comparable to physician-based prehospital care - a retrospective longitudinal study.

Acute pain is a common reason for summoning emergency medical services (EMS). Yet in several countries the law restricts opioid-based analgesia administration to physicians. Telemedical support of paramedics is a novel approach to enable timely treatment under the guidance of a physician. In this retrospective observational study, conducted in the EMS of Aachen, Germany, the analgesic quality and occurrence of adverse events were compared between telemedically-supported paramedics (July-December, 2014) and a historical control group (conventional on-scene EMS physicians; January-March, 2014). INCLUSION CRITERIA: pain (initial numerical rating scale (NRS) ≥5) and/or performed analgesia. Telemedically-assisted analgesia was performed in 149 patients; conventional analgesia in 199 control cases. Teleconsultation vs. CONTROL: Initial NRS scores were 8.0 ± 1.5 and 8.1 ± 1.7. Complete NRS documentation was carried out in 140/149 vs. 130/199 cases, p < 0.0001. NRS scores were reduced by 4.94 ± 2.01 and 4.84 ± 2.28 (p = 0.5379), leading to mean NRS scores at emergency room arrival of 3.1 ± 1.7 vs. 3.3 ± 1.9 (p = 0.5229). No severe adverse events occurred in either group. Clinically relevant pain reduction was achieved in both groups. Thus, the concept of remote physician-based telemedically-delegated analgesia by paramedics is effective compared to analgesia by on-scene EMS physicians and safe.

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.

Implementation phase of a multicentre prehospital telemedicine system to support paramedics: feasibility and possible limitations.

BACKGROUND: Legal regulations often limit the medical care that paramedics can provide. Telemedical solutions could overcome these limitations by remotely providing expert support. Therefore, a mobile telemedicine system to support paramedics was developed. During the implementation phase of this system in four German emergency medical services (EMS), the feasibility and possible limitations of this system were evaluated. METHODS: After obtaining ethical approval and providing a structured training program for all medical professionals, the system was implemented on three paramedic-staffed ambulances on August 1st, 2012. Two more ambulances were included subsequently during this month. The paramedics could initiate a consultation with EMS physicians at a teleconsultation centre. Telemedical functionalities included audio communication, real-time vital data transmission, 12-lead electrocardiogram, picture transmission on demand, and video streaming from a camera embedded into the ceiling of each ambulance. After each consultation, telephone-based debriefings were conducted. Data were retrieved from the documentation protocols of the teleconsultation centre and the EMS. RESULTS: During a one month period, teleconsultations were conducted during 35 (11.8%) of 296 emergency missions with a mean duration of 24.9 min (SD 12.5). Trauma, acute coronary syndromes, and circulatory emergencies represented 20 (57%) of the consultation cases. Diagnostic support was provided in 34 (97%) cases, and the administration of 50 individual medications, including opioids, was delegated by the teleconsultation centre to the paramedics in 21 (60%) missions (range: 1-7 per mission). No medical complications or negative interpersonal effects were reported. All applications functioned as expected except in one case in which the connection failed due to the lack of a viable mobile network. CONCLUSION: The feasibility of the telemedical approach was demonstrated. Teleconsultation enabled early initiation of treatments by paramedics operating under the real-time medical direction. Teleconsultation can be used to provide advanced care until the patient is under a physician's care; moreover, it can be used to support the paramedics who work alone to provide treatment in non-life-threatening cases. Non-availability of mobile networks may be a relevant limitation. A larger prospective controlled trial is needed to evaluate the rate of complications and outcome effects.