A Longer Tpeak-Tend Interval Is Associated with a Higher Risk of Death: A Meta-Analysis.

A noninvasive tool for cardiovascular risk stratification has not yet been established in the clinical routine analysis. Previous studies suggest a prolonged Tpeak-Tend interval (the interval from the peak to the end of the T-wave) to be predictive of death. This meta-analysis was designed to systematically evaluate the association of the Tpeak-Tend interval with mortality outcomes. Medline (via PubMed), Embase and the Cochrane Library were searched from 1 January 2008 to 21 July 2020 for articles reporting the ascertainment of the Tpeak-Tend interval and observation of all-cause-mortality. The search yielded 1920 citations, of which 133 full-texts were retrieved and 29 observational studies involving 23,114 patients met the final criteria. All-cause deaths had longer Tpeak-Tend intervals compared to survivors by a standardized mean difference of 0.41 (95% CI 0.23-0.58) and patients with a long Tpeak-Tend interval had a higher risk of all-cause death compared to patients with a short Tpeak-Tend interval by an overall odds ratio of 2.33 (95% CI 1.57-3.45). Heart rate correction, electrocardiographic (ECG) measurement methods and the selection of ECG leads were major sources of heterogeneity. Subgroup analyses revealed that heart rate correction did not affect the association of the Tpeak-Tend interval with mortality outcomes, whereas this finding was not evident in all measurement methods. The Tpeak-Tend interval was found to be significantly associated with all-cause mortality. Further studies are warranted to confirm the prognostic value of the Tpeak-Tend interval.

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.

Telemedical support for prehospital Emergency Medical Service (TEMS trial): study protocol for a randomized controlled trial.

BACKGROUND: Increasing numbers of emergency calls, shortages of Emergency Medical Service (EMS), physicians, prolonged emergency response times and regionally different quality of treatment by EMS physicians require improvement of this system. Telemedical solutions have been shown to be beneficial in different emergency projects, focused on specific disease patterns. Our previous pilot studies have shown that the implementation of a holistic prehospital EMS teleconsultation system, between paramedics and experienced tele-EMS physicians, is safe and feasible in different emergency situations. We aim to extend the clinical indications for this teleconsultation system. We hypothesize that the use of a tele-EMS physician is noninferior regarding the occurrence of system-induced patient adverse events and superior regarding secondary outcome parameters, such as the quality of guideline-conforming treatment and documentation, when compared to conventional EMS-physician treatment. METHODS/DESIGN: Three thousand and ten patients will be included in this single-center, open-label, randomized controlled, noninferiority trial with two parallel arms. According to the inclusion criteria, all emergency cases involving adult patients who require EMS-physician treatment, excluding life-threatening cases, will be randomly assigned by the EMS dispatching center into two groups. One thousand five hundred and five patients in the control group will be treated by a conventional EMS physician on scene, and 1505 patients in the intervention group will be treated by paramedics who are concurrently instructed by the tele-EMS physicians at the teleconsultation center. The primary outcome measure will include the rate of treatment-specific adverse events in relation to the kind of EMS physician used. The secondary outcome measures will record the specific treatment-associated quality indicators. DISCUSSION: The evidence underlines the better quality of service using telemedicine networks between medical personnel and medical experts in prehospital emergency care, as well as in other medical areas. The worldwide unique EMS teleconsultation system in Aachen has been optimized and evaluated in pilot studies and subsequently integrated into routine use for a broad spectrum of indications. It has enabled prompt, safe and efficient patient treatment with optimized use of the "resource" EMS physician. There is, however, a lack of evidence as to whether the advantages of the teleconsultation system can be replicated in wider-ranging EMS-physician indications (excluding life-threatening emergency calls). TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02617875 . Registered on 24 November 2015.

Impact of Helicopter Emergency Medical Service in Traumatized Patients: Which Patient Benefits Most?

INTRODUCTION: The Helicopter Emergency Medical Service (HEMS) was established for the prehospital trauma care of patients. Improved rescue times and increased coverage areas are discussed as specific advantages of HEMS. We recently found evidence that HEMS exerts beneficial effects on outcomes for severely injured patients. However, it still remains unknown which group of trauma patients might benefit most from HEMS rescue. Consequently, the unique aim of this study was to reveal which patients might benefit most from HEMS rescue. METHODS: Trauma patients (ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2002 and 2012 were analysed using the TraumaRegister DGU. A multivariate regression analysis was used to reveal the survival benefit between different trauma populations. RESULTS: The study included 52 281 trauma patients. Of these, 68.8% (35 974) were rescued by GEMS and 31.2% (16 307) by HEMS. HEMS patients were more severely injured compared to GEMS patients (ISS: HEMS 24.8±13.5 vs. GEMS 21.7±18.0) and more frequently suffered traumatic shock (SBP sys <90mmHg: HEMS 18.3% vs. GEMS 14.8%). However, logistic regression analysis revealed that HEMS rescues resulted in an overall survival benefit compared to GEMS (OR 0.81, 95% CI [0.75-0.87], p<0.001, Nagelkerke's R squared 0.526, area under the ROC curve 0.922, 95% CI [0.919-0.925]). Analysis of specific subgroups demonstrated that patients aged older than 55 years (OR 0.62, 95% CI [0.50-0.77]) had the highest survival benefit after HEMS treatment. Furthermore, HEMS rescue had the most significant impact after 'low falls' (OR 0.68, 95% CI [0.55-0.84]) and in the case of minor severity injuries (ISS 9-15) (OR 0.66, 95% CI [0.49-0.88]). CONCLUSIONS: In general, trauma patients benefit from HEMS rescue with in-hospital survival as the main outcome parameter. Focusing on special subgroups, middle aged and older patients, low-energy trauma, and minor severity injuries had the highest survival benefit when rescued by HEMS. Further studies are required to determine the potential reasons of this benefit.

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.

Is paper-based documentation in an emergency medical service adequate for retrospective scientific analysis? An evaluation of a physician-run service.

OBJECTIVE: To investigate if paper-based documentation in the authors' emergency medical service (EMS) satisfies scientific requirements. METHODS: From 1 July 2007 to 28 February 2008, data from all paper-based protocols of a physician-run EMS in Aachen, Germany, were transferred to a SQL database (n=4815). Database queries were conducted after personal data had been anonymised. Documentation ratios of 11 individual parameters were analysed at two points in time (T1, scene; T2, arrival in emergency department). The calculability of the Mainz Emergency Evaluation Score (MEES, embracing seven vital parameters) was investigated. The calculability of the Revised Trauma Score (RTS) was also determined for all trauma patients (n=408). Fisher's exact test was used to compare differences in ratios at T1 versus T2. RESULTS: The documentation ratios of vital parameters ranged from 99.33% (Glasgow Coma Scale, T1) to 40.31% (respiratory rate, T2). The calculability of the MEES was poor (all missions: 28.31%, T1; 22.40%, T2; p<0.001). In missions that required cardiopulmonary resuscitation (n=87), the MEES was calculable in 9.20% of patients at T1 and 29.89% at T2 (p<0.001). In trauma missions, the RTS was calculable in 37.26% at T1 and 27.70% at T2 (p=0.004). CONCLUSIONS: Documentation of vital parameters is carried out incompletely, and documentation of respiratory rate is particularly poor, making calculation of accepted emergency scores infeasible for a significant fraction of a given test population. The suitability of paper-based documentation is therefore limited. Electronic documentation that includes real-time plausibility checks might improve data quality. Further research is warranted.