[E-health in emergency medicine - the research project Med-on-@ix]

Mapping Digital Public Health Interventions Among Existing Digital Technologies and Internet-Based Interventions to Maintain and Improve Population Health in Practice: Scoping Review

BACKGROUND

The rapid progression and integration of digital technologies into public health have reshaped the global landscape of health care delivery and disease prevention. In pursuit of better population health and health care accessibility, many countries have integrated digital interventions into their health care systems, such as web-based consultations, electronic health records, and telemedicine. Despite the increasing prevalence and relevance of digital technologies in public health and their varying definitions, there has been a shortage of studies examining whether these technologies align with the established definition and core characteristics of digital public health (DiPH) interventions. Hence, the imperative need for a scoping review emerges to explore the breadth of literature dedicated to this subject.

OBJECTIVE

This scoping review aims to outline DiPH interventions from different implementation stages for health promotion, primary to tertiary prevention, including health care and disease surveillance and monitoring. In addition, we aim to map the reported intervention characteristics, including their technical features and nontechnical elements.

METHODS

Original studies or reports of DiPH intervention focused on population health were eligible for this review. PubMed, Web of Science, CENTRAL, IEEE Xplore, and the ACM Full-Text Collection were searched for relevant literature (last updated on October 5, 2022). Intervention characteristics of each identified DiPH intervention, such as target groups, level of prevention or health care, digital health functions, intervention types, and public health functions, were extracted and used to map DiPH interventions. MAXQDA 2022.7 (VERBI GmbH) was used for qualitative data analysis of such interventions' technical functions and nontechnical characteristics.

RESULTS

In total, we identified and screened 15,701 records, of which 1562 (9.94%) full texts were considered relevant and were assessed for eligibility. Finally, we included 185 (11.84%) publications, which reported 179 different DiPH interventions. Our analysis revealed a diverse landscape of interventions, with telemedical services, health apps, and electronic health records as dominant types. These interventions targeted a wide range of populations and settings, demonstrating their adaptability. The analysis highlighted the multifaceted nature of digital interventions, necessitating precise definitions and standardized terminologies for effective collaboration and evaluation.

CONCLUSIONS

Although this scoping review was able to map characteristics and technical functions among 13 intervention types in DiPH, emerging technologies such as artificial intelligence might have been underrepresented in our study. This review underscores the diversity of DiPH interventions among and within intervention groups. Moreover, it highlights the importance of precise terminology for effective planning and evaluation. This review promotes cross-disciplinary collaboration by emphasizing the need for clear definitions, distinct technological functions, and well-defined use cases. It lays the foundation for international benchmarks and comparability within DiPH systems. Further research is needed to map intervention characteristics in this still-evolving field continuously.

TRIAL REGISTRATION

PROSPERO CRD42021265562; https://tinyurl.com/43jksb3k.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33404.

TeleNeurological evaluation and Support for the Emergency Department (TeleNS-ED): protocol for an open-label clinical trial

INTRODUCTION

The COVID-19 pandemic compelled health systems to protect patients and medical personnel during transit in hospitals by minimising transfers, prompting the use of telehealth systems. In the field of neurology, telemedicine has been used in emergency settings for acute stroke management between spoke and hub hospital networks, where good outcomes have been achieved. However, data on the use of telemedicine in non-stroke acute neurological conditions accessing the emergency department (ED) are currently missing.

METHODS AND ANALYSES

This is an interventional, open-label trial on the use of teleconsultation in the ED for neurological diseases other than stroke. The study aims to develop a remote consultancy system (TeleNeurological Evaluation and Support, TeleNS) for patients with acute neurological symptoms referred to hospital facilities without a 24-hour availability of a neurologist consultant (spoke hospitals). The study population will include 100 ED patients referred to two spoke hospitals in 6 months, who will be asked to perform teleconsultation instead of inperson visits. As a control group, retrospectively available data from patients admitted to the ED of spoke hospitals during the same time period over the last 2 years will be evaluated. The primary objective is to assess whether a TeleNS for the ED guarantees a faster but qualitatively non-inferior diagnostic/therapeutic work-up if compared with inperson examination, assuring the availability of all the necessary examinations and treatments with consistent time-saving.

ETHICS AND DISSEMINATION

The trial was designed following the national guidelines on clinical investigation on telemedicine provided by the Italian Ministry of Health and according to the Standard Protocol Items for Randomized Trials statement guidelines. This research protocol was approved by Comitato Etico Area Vasta Emilia Nord in September 2020 (number/identification: 942/2020/DISP/AOUMO SIRER ID 805) and was written without patient involvement. Patients' associations will be involved in the dissemination of study design and results. The results of the study will be presented during scientific symposia or published in scientific journals.

TRIAL REGISTRATION NUMBER

NCT04611295.

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.

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.

Evaluation of an Anesthesia Dashboard Functional Model Based on a Manufacturer-Independent Communication Standard: Comparative Feasibility Study

Background

Current anesthesia workspaces consist of several technical devices, such as patient monitors, anesthesia machines, among others. Commonly, they are produced by different manufacturers; thus, they differ in terms of their modus operandi, user interface, and representation of alarms. Merging the information from these devices using a single joint protocol and displaying it in a single graphical user interface could lead to a general improvement in perioperative management. For this purpose, the recently approved and published Institute of Electrical and Electronics Engineers 11073 service-oriented device connectivity standard was implemented.

Objective

This paper aims to develop and then evaluate an anesthesia workstation (ANWS) functional model in terms of usability, fulfillment of clinical requirements, and expected improvements in patient safety.

Methods

To compare the self-developed ANWS with the conventional system, a pilot observational study was conducted at the University Hospital Aachen, Germany. A total of 5 anesthesiologists were asked to perform different tasks using the ANWS and then the conventional setup. For evaluation purposes, response times were measured and an interaction-centered usability test with an eye-tracking system was carried out. Finally, the subjects were asked to fill in a questionnaire in order to measure user satisfaction.

Results

Response times were significantly higher when using the ANWS, but decreased considerably after one repetition. Furthermore, usability was rated as excellent (≥95) according to the System Usability Scale score, and the majority of clinical requirements were met.

Conclusions

In general, the results were highly encouraging, considering that the ANWS was only a functional model, as well as the lack of training of the participants. However, further studies are necessary to improve the universal user interface and the interplay of the various networked devices.

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.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1781-2) contains supplementary material, which is available to authorized users.

[Current capabilities of telemedicine in anaesthesiology]

Because of an ageing population and a relative lack of professionals, the German health system is under great pressure. In rural regions in particular, anesthesiology is also affected - nursing staff, anesthetists, intensive care physicians, and emergency physicians often have to be supported by freelancers from other regions and from abroad - at least periodically. In addition to the increasing number of treatments, the potential quality of therapy is also increasing owing to progress in medical research. Against this background the need for resources is increasing to ensure the optimal quality of treatment. This applies to all clinical disciplines, including all sections of anesthesiology - especially in economically underdeveloped regions where highly qualified experts are lacking. In various cases it is not the physical attendance or manual skills of experts that is primarily requested on-site, but rather their medical expertise and experience. Therefore, telemedicine systems are suitable for closing these gaps very effectively and efficiently. In the various anesthesiological sub-sections the number of scientific papers published to date varies. For anesthesia and pain therapy only a few telemedical applications or concepts have been reported in the literature. However, in tele-intensive care medicine and tele-emergency medicine several national and international research projects have successfully been carried out, leading to established routine systems in some cases.

Cortisol and alpha-amylase as stress response indicators during pre-hospital emergency medicine training with repetitive high-fidelity simulation and scenarios with standardized patients

BACKGROUND

In emergency medicine, the benefits of high-fidelity simulation (SIM) are widely accepted and standardized patients (SP) are known to mimic real patients accurately. However, only limited data are available concerning physicians' stress markers within these training environments. The aim of this pilot study was to investigate repetitive stress among healthcare professionals in simulated pre-hospital emergency scenarios using either SIM or SPs.

METHODS

Teams with one emergency medical services (EMS) physician and two paramedics completed three SIM scenarios and two SP scenarios consecutively. To evaluate stress, salivary cortisol and alpha-amylase were measured in saliva samples taken before, during and after the scenarios.

RESULTS

A total of 14 EMS physicians (29% female; mean age: 36.8 ± 5.0 years; mean duration of EMS-experience: 9.1 ± 5.8 years) and 27 paramedics (11% female; age: 30.9 ± 6.9 years; EMS experience: 8.1 ± 6.0 years) completed the study. Alpha-amylase and cortisol levels did not differ significantly between the two professions. Cortisol values showed a gradual and statistically significant reduction over time but little change was observed in response to each scenario. In contrast, alpha-amylase activity increased significantly in response to every SIM and SP scenario, but there was no clear trend towards an overall increase or decrease over time.

CONCLUSION

Increases in salivary alpha-amylase activity suggest that both SIM and SP training produce stress among emergency healthcare professionals. Corresponding increases in salivary cortisol levels were not observed. Among physicians in the emergency setting, it appears that alpha-amylase provides a more sensitive measure of stress levels than cortisol.

LiveCity

The goal of emergency medicine is to treat time-critical diseases and conditions to reduce morbidity and mortality. The improvement of emergency medicine is an important topic for governments worldwide. A common problem is the inevitable lack of support by emergency doctors, when paramedics need their assistance at the emergency site but are without an emergency doctor. Video-communication in real time from the emergency site to an emergency doctor, offers an opportunity to enhance the quality of emergency medicine. The core piece of this study is a video camera system called “LiveCity camera”, enabling real-time high quality video connection of paramedics and emergency doctors. The impact of video communication on emergency medicine is clearly appreciated among providers, based upon the extent of agreement that has been stated in this study´s questionnaire by doctors and paramedics. This study is part of the FP7-European Union funded research project “LiveCity” (Grant Agreement No. 297291).

Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound

BACKGROUND

Transcranial color-coded sonography (TCCS) has proved to be a fast and reliable tool for the detection of middle cerebral artery (MCA) occlusions in a hospital setting. In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination.

METHODS

Following a '911 stroke code' call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team. In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging (CTA, MRA) and the final discharge diagnosis from standard patient-centered stroke care.

RESULTS

We enrolled '232 stroke code' patients with follow-up data available in 102 patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as 'stroke mimics'. MCA occlusion was diagnosed in ten patients, while internal carotid artery (ICA) occlusion/high-grade stenosis leading to reversal of anterior cerebral artery flow was diagnosed in four patients. The initial working diagnosis 'any stroke' showed a sensitivity of 94% and a specificity of 48%. 'Major MCA or ICA stroke' diagnosed by mobile ultrasound showed an overall sensitivity of 78% and specificity of 98%.

CONCLUSIONS

The study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment.

Prehospital digital photography and automated image transmission in an emergency medical service - an ancillary retrospective analysis of a prospective controlled trial

BACKGROUND

Still picture transmission was performed using a telemedicine system in an Emergency Medical Service (EMS) during a prospective, controlled trial. In this ancillary, retrospective study the quality and content of the transmitted pictures and the possible influences of this application on prehospital time requirements were investigated.

METHODS

A digital camera was used with a telemedicine system enabling encrypted audio and data transmission between an ambulance and a remotely located physician. By default, images were compressed (jpeg, 640 x 480 pixels). On occasion, this compression was deactivated (3648 x 2736 pixels). Two independent investigators assessed all transmitted pictures according to predefined criteria. In cases of different ratings, a third investigator had final decision competence. Patient characteristics and time intervals were extracted from the EMS protocol sheets and dispatch centre reports.

RESULTS

Overall 314 pictures (mean 2.77 ± 2.42 pictures/mission) were transmitted during 113 missions (group 1). Pictures were not taken for 151 missions (group 2). Regarding picture quality, the content of 240 (76.4%) pictures was clearly identifiable; 45 (14.3%) pictures were considered "limited quality" and 29 (9.2%) pictures were deemed "not useful" due to not/hardly identifiable content. For pictures with file compression (n = 84 missions) and without (n = 17 missions), the content was clearly identifiable in 74% and 97% of the pictures, respectively (p = 0.003). Medical reports (n = 98, 32.8%), medication lists (n = 49, 16.4%) and 12-lead ECGs (n = 28, 9.4%) were most frequently photographed. The patient characteristics of group 1 vs. 2 were as follows: median age - 72.5 vs. 56.5 years, p = 0.001; frequency of acute coronary syndrome - 24/113 vs. 15/151, p = 0.014. The NACA scores and gender distribution were comparable. Median on-scene times were longer with picture transmission (26 vs. 22 min, p = 0.011), but ambulance arrival to hospital arrival intervals did not differ significantly (35 vs. 33 min, p = 0.054).

CONCLUSIONS

Picture transmission was used frequently and resulted in an acceptable picture quality, even with compressed files. In most cases, previously existing "paper data" was transmitted electronically. This application may offer an alternative to other modes of ECG transmission. Due to different patient characteristics no conclusions for a prolonged on-scene time can be drawn. Mobile picture transmission holds important opportunities for clinical handover procedures and teleconsultation.

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 83270177.

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.

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.

Reducing hardware risks in the development of Telematic rescue assistance systems: a methodology

In developed countries many of the main causes of death such as heart attack and stroke usually strike outside of hospitals. Therefore patient outcome depends to a large extent on the quality of preclinical care. In order to improve it, Telematic Rescue Assistance Systems (TRAS) are being developed. They transmit vital signs, audio and sometimes video data from the rescue team to an emergency physician at a remote site, thus enabling this specialist to assist in diagnosis and treatment. Not only is specialist expertise brought to the emergency site, but also time to definite treatment is reduced, as specialists are involved earlier and hospitals are informed in advance about incoming patients. Due to their use in emergencies, risks to the proper functioning of TRAS hardware have to be kept as low as possible. Adequate methods for risk assessment have to be chosen, since the use of an inadequate method can result in a cumbersome resource-intensive process, while at the same time major risks are being overlooked. This paper proposes a methodology for reducing hardware risks in the development of TRAS.