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.

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.

Neurogenic pulmonary edema following seizures: A retrospective computed tomography study.

INTRODUCTION: Data on the frequency and clinical relevance of neurogenic pulmonary edema (NPE) following epileptic seizures are limited. The aim of the present study was to analyze computed tomography (CT) examinations in patients with previous seizures. METHOD: Incidence of NPE and related clinical factors were retrospectively assessed in patients admitted because of epileptic seizures who underwent thoracic CT imaging as part of emergency diagnostics. RESULTS: Between January 2010 and January 2016, we included all patients admitted with the International Classification of Diseases (ICD) diagnosis code of epileptic seizure or epilepsy and who underwent CT imaging, including visualization of the lungs, as part of emergency diagnostics. Of the 47 included patients, 26 patients had suffered from generalized convulsive seizures (GCS), 17 patients had focal seizures with impaired and 4 without impaired consciousness. Signs of NPE were present in 5 out of 47 patients; all 5 patients had GCS prior to thoracic CT scan (i.e., 19% of patients with GCS). In four out of five cases, a single seizure was described; in one case, the seizure was only partially witnessed, but the indirect clinical signs strongly suggested a GCS. Related factors such as the initial respiratory rate or the initial pCO2 value were not significantly different in patients with and without signs of NPE. CONCLUSIONS: The highly selected and biased patient group warrants caution in the interpretation of the study results. Our data, however, confirm that signs of NPE appear to be rather frequent in patients with GCS. Its clinical significance as regards morbidity and sudden death in epilepsy is discussed.

Guideline adherence in acute coronary syndromes between telemedically supported paramedics and conventional on-scene physician care: A longitudinal pre-post intervention cohort study.

Health informatics applications reduce time intervals in acute coronary syndromes, but their impact on guideline adherence is unknown. This pre-post intervention study compared guideline adherence between telemedically supported (n = 101, April 2014-July 2015) and conventional on-scene care (n = 120, January 2014-March 2014) in acute coronary syndrome. A multivariate logistic regression was performed for dependent variables: adverse events 0 versus 0, p = NA; electrocardiogram 101 versus 120, p = NA; acetylic salicylic acid 91 versus 102, p = 0.21; heparin 92 versus 112, p = 0.99; morphine 96 versus 107, p = 0.33; oxygen 83 versus 102, p = 0.92; glyceroltrinitrate 55 versus 90, p = 0.038; correct destination: 100 versus 119, p = 1.0. The time from ambulance arrival to hospital arrival was prolonged with telemedicine: 48.7 ± 11 min versus 35.5 ± 8.1 min, p < 0.001. Guideline adherence showed no differences except for glyceroltrinitrate. Prolonged time requirements are critical, though explainable. However, this approach enables a timely and high-quality backup strategy if only paramedics are on-scene.

Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic-clonic seizures from syncopes.

Concentrations of serum creatine kinase (CK) and serum lactate are frequently measured to help differentiate between generalized tonic-clonic seizures (GTCS) and syncope. The aim of this prospective cohort study was to systematically compare these two markers. The primary outcome is the measurement of serum lactate and CK in blood samples drawn within 2 h of the event in patients admitted with either a GTCS (n = 49) or a syncope (n = 36). Furthermore, the specificity and sensitivity of serum lactate and CK are determined as diagnostic markers in distinguishing between GTCS and syncope. GTCS patients have significantly higher serum lactate levels compared to syncope patients (p < 0.001). In contrast, CK does not differ between groups at admission. Regarding the first hour after the seizure, we identify a cut-off for serum lactate of 2.45 mmol/l for diagnosing GTCS as the cause of an impairment of consciousness with a sensitivity of 0.94 and a specificity of 0.93 (AUC: 0.97; 95% CI 0.94-1.0). In the second hour after the event, the ROC analysis yields similar results (AUC: 0.94; 95% CI 0.85-1.0). Serum lactate is a sensitive and specific diagnostic marker to discriminate GTCS from syncope and is superior to CK early after admission to the emergency department.

Blood pressure management and guideline adherence in hypertensive emergencies and urgencies: A comparison between telemedically supported and conventional out-of-hospital care.

Prehospital hypertensive emergencies and urgencies are common, but evidence is lacking. Telemedically supported hypertensive emergencies and urgencies were prospectively collected (April 2014-March 2015) and compared retrospectively with a historical control group of on-scene physician care in the emergency medical service of Aachen, Germany. Blood pressure management and guideline adherence were evaluated. Telemedical (n=159) vs conventional (n=172) cases: blood pressure reductions of 35±24 mm Hg vs 44±23 mm Hg revealed a group effect adjusted for baseline differences (P=.0006). Blood pressure management in categories: no reduction 6 vs 0 (P=.0121); reduction ≤25% (recommended range) 113 vs 110 patients (P=.2356); reduction >25% to 30% 13 vs 29 (0.020); reduction >30% 12 vs 16 patients (P=.5608). The telemedical approach led to less pronounced blood pressure reductions and a tendency to improved guideline adherence. Telemedically guided antihypertensive care may be an alternative to conventional care especially for potentially underserved areas.

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.

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.

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.

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).

Airway and ventilator management in trauma patients.

PURPOSE OF REVIEW: Securing the airway to provide sufficient oxygenation and ventilation is of paramount importance in the management of all types of emergency patients. Particularly in severely injured patients, strategies should be adapted according to useful recent literature findings. RECENT FINDINGS: The role of out-of-hospital endotracheal intubation in patients with severe traumatic brain injury as prevention of hypoxia still persists, and the ideal neuromuscular blocking agent will be a target of research. Standardized monitoring, including capnography and the use of standardized medication protocols without etomidate, can reduce further complications. Prophylactic noninvasive ventilation may be useful for patients with blunt chest trauma without respiratory insufficiency. SUMMARY: An algorithm-based approach to airway management can prevent complications due to inadequate oxygenation or procedural difficulties in trauma patients; therefore, advanced equipment for handling a difficult airway is needed. After securing the airway, ventilation must be monitored by capnography, and normoventilation involving the early use of protective ventilation with low-tidal volume and moderate positive end-expiratory pressure must be the target. After early identification of patients with blunt chest trauma at risk for respiratory failure, noninvasive ventilation might be a treatment strategy, which should be evaluated in future research.

Evaluation of a newly developed media-supported 4-step approach for basic life support training.

OBJECTIVE: The quality of external chest compressions (ECC) is of primary importance within basic life support (BLS). Recent guidelines delineate the so-called 4"-step approach" for teaching practical skills within resuscitation training guided by a certified instructor. The objective of this study was to evaluate whether a "media-supported 4-step approach" for BLS training leads to equal practical performance compared to the standard 4-step approach. MATERIALS AND METHODS: After baseline testing, 220 laypersons were either trained using the widely accepted method for resuscitation training (4-step approach) or using a newly created "media-supported 4-step approach", both of equal duration. In this approach, steps 1 and 2 were ensured via a standardised self-produced podcast, which included all of the information regarding the BLS algorithm and resuscitation skills. Participants were tested on manikins in the same mock cardiac arrest single-rescuer scenario prior to intervention, after one week and after six months with respect to ECC-performance, and participants were surveyed about the approach. RESULTS: Participants (age 23 ± 11, 69% female) reached comparable practical ECC performances in both groups, with no statistical difference. Even after six months, there was no difference detected in the quality of the initial assessment algorithm or delay concerning initiation of CPR. Overall, at least 99% of the intervention group (n = 99; mean 1.5 ± 0.8; 6-point Likert scale: 1 = completely agree, 6 = completely disagree) agreed that the video provided an adequate introduction to BLS skills. CONCLUSIONS: The "media-supported 4-step approach" leads to comparable practical ECC-performance compared to standard teaching, even with respect to retention of skills. Therefore, this approach could be useful in special educational settings where, for example, instructors' resources are sparse or large-group sessions have to be prepared.

Feasibility of prehospital teleconsultation in acute stroke--a pilot study in clinical routine.

BACKGROUND: Inter-hospital teleconsultation improves stroke care. To transfer this concept into the emergency medical service (EMS), the feasibility and effects of prehospital teleconsultation were investigated. METHODOLOGY/PRINCIPAL FINDINGS: Teleconsultation enabling audio communication, real-time video streaming, vital data and still picture transmission was conducted between an ambulance and a teleconsultation center. Pre-notification of the hospital was carried out with a 14-item stroke history checklist via e-mail-to-fax. Beside technical assessments possible influences on prehospital and initial in-hospital time intervals, prehospital diagnostic accuracy and the transfer of stroke specific data were investigated by comparing telemedically assisted prehospital care (telemedicine group) with local regular EMS care (control group). All prehospital stroke patients over a 5-month period were included during weekdays (7.30 a.m.-4.00 p.m.). In 3 of 18 missions partial dropouts of the system occurred; neurological co-evaluation via video transmission was conducted in 12 cases. The stroke checklist was transmitted in 14 cases (78%). Telemedicine group (n = 18) vs. control group (n = 47): Prehospital time intervals were comparable, but in both groups the door to brain imaging times were longer than recommended (median 59.5 vs. 57.5 min, p = 0.6447). The prehospital stroke diagnosis was confirmed in 61% vs. 67%, p = 0.8451. Medians of 14 (IQR 9) vs. 5 (IQR 2) stroke specific items were transferred in written form to the in-hospital setting, p<0.0001. In 3 of 10 vs. 5 of 27 patients with cerebral ischemia thrombolytics were administered, p = 0.655. CONCLUSIONS: Teleconsultation was feasible but technical performance and reliability have to be improved. The approach led to better stroke specific information; however, a superiority over regular EMS care was not found and in-hospital time intervals were unacceptably long in both groups. The feasibility of prehospital tele-stroke consultation has future potential to improve emergency care especially when no highly trained personnel are on-scene. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register (ISRCTN) ISRCTN83270177.

Teleconsultation in pre-hospital emergency medical services: real-time telemedical support in a prospective controlled simulation study.

BACKGROUND: Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible. In preparation for bringing such a system into practice within the research project "Med-on-@ix", a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing. MATERIAL AND METHODS: In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario. RESULTS: Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p=0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p=0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p=0.0421); synchronized shock (6/14 vs. 14/15; p=0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p=0.0092); mean time to inform trauma centre 547 vs. 189 s (p=0.0001). No significant impairment of performance was detected in TMA groups. CONCLUSIONS: In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.

Influence of pre-course assessment using an emotionally activating stimulus with feedback: a pilot study in teaching Basic Life Support.

BACKGROUND: Cardiopulmonary resuscitation (CPR) mastery continues to challenge medical professionals. The purpose of this study was to determine if an emotional stimulus in combination with peer or expert feedback during pre-course assessment effects future performance in a single rescuer simulated cardiac arrest. METHODS: First-year medical students (n=218) without previous medical knowledge were randomly assigned to one of the study groups and asked to take part in a pre-course assessment: Group 1: after applying an emotionally activating stimulus an expert (instructor) gave feedback on CPR performance (Ex). Group 2: after applying the same stimulus feedback was provided by a peer from the same group (Pe); Group 3: standard without feedback (S). Following pre-course assessment, all subjects received a standardized BLS-course, were tested after 1 week and 6 months later using single-rescuer-scenario, and were surveyed using standardized questionnaires (6-point-likert-scales: 1=completely agree, 6=completely disagree). RESULTS: Participants exposed to stimulus demonstrated superior performance concerning compression depth after 6 months independent of feedback-method (Ex: 65.85% [p=0.0003]; Pe: 57.50% [p=0.0076] vs. 21.43%). The expert- more than the peer-group was emotionally more activated in initial testing, Ex: 3.26 ± 1.35 [p ≤ 0.0001]; Pe: 3.73 ± 1.53 [p=0.0319]; S: 4.25 ± 1.37) and more inspired to think about CPR (Ex: 2.03 ± 1.37 [p=0.0119]; Pe: 2.07 ± 1.14 [p=0.0204]; S: 2.60 ± 1.55). After 6 months this activation effect was still detectable in the expert-group (p=0.0114). CONCLUSIONS: The emotional stimulus approach to BLS-training seems to impact the ability to provide adequate compression depth up to 6 months after training. Furthermore, pre-course assessment helped to keep the participants involved beyond initial training.