Decision Support Capabilities of Telemedicine in Emergency Prehospital Care: Systematic Review.

BACKGROUND: Telemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation. OBJECTIVE: Our objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care. METHODS: This systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently. RESULTS: Out of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use; however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes. CONCLUSIONS: The information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.

Stress and decision-making in resuscitation: A systematic review.

BACKGROUND: During resuscitation decisions are made frequently and based on limited information in a stressful environment. AIM: This systematic review aimed to identify human factors affecting decision-making in challenging or stressful situations in resuscitation. The secondary aim was to identify methods of improving decision-making performance under stress. METHODS: The databases PubMed, EMBASE and The Cochrane Library were searched from their commencement to the 13th of April 2019. MeSH terms and key words were combined (Stress* OR "human factor") AND Decision. Articles were included if they involved decision makers in medicine where decisions were made under challenging circumstances, with a comparator group and an outcome measure relating to change in decision-making performance. RESULTS: 22,368 records in total were initially identified, from which 82 full text studies were reviewed and 16 finally included. The included studies ranged from 1995 to 2018 and included a total of 570 participants. The studies were conducted in several different countries and settings, with participants of varying experience and backgrounds. Of the 16 studies, 5 were randomised controlled trials, 3 of which were deemed to have a high risk of bias. The stressors identified were (i) illness severity (ii) socio-evaluative, (iii) noise, (iv) fatigue. The mitigators identified were (i) cognitive aids including checklists, (ii) stress management training and (iii) meditation. CONCLUSIONS: Human factors contributing to decision-making during resuscitation are identified and can be mitigated by tailored stress training and cognitive aids. Understanding these factors may have implications for clinician education and the development of decision-support tools.