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

[The tele-emergency physician system as a tool in preclinical emergency care: A stocktaking report on the quality of care based on selected characteristics]

INTRODUCTION

Due to the increasing proportion of older people in the German population, the age group-specific burden of disease is also rising, which consequently leads to an escalating need for emergency medical care in the preclinical sector. Within the German health care system, the growing shortage of physicians and the associated deficit of emergency physicians are further aggravating factors, which can lead to relevant gaps in care.

METHODS

Through a systematic literature search for the period from January 1, 2000 to March 1, 2023 on prehospital telemedical emergency services (tele-EMS), selected quantitative and qualitative characteristics according to the PICOS scheme and the PRISMA statement were made available as examples; these were then used to critically categorize the quality of telemedically supported emergency care in Germany.

RESULTS

The 23 selected publications comprised 17 clinical trials (including five quasi-experimental, ten observational, and two mixed-methods studies), four simulation studies, and two surveys. The incidence of technical problems ranged from 3% to 20% in the trials. Overall, the majority showed benefits in terms of faster availability of emergency medical expertise on scene together with a shortening of the treatment-free interval. The studies also indicated that patient registrations at the hospital providing further treatment took place at an earlier time. Furthermore, a reduction in the number and duration of emergency medical interventions was also evident.

CONCLUSION

Currently, there still is a considerable need for optimization both with regard to the nationwide establishment of the tele-EMS and its design in already existing digital support systems. To be able to guarantee a customized continuity of care, a goal-oriented application and expansion of a digital infrastructure in the field of emergency medicine offers an option for guaranteeing up-to-date and qualitatively acceptable preclinical emergency care.

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.

Medical Emergency Datasets Can Improve the Comprehensiveness of Handover Information: A Simulation Study

Background: Access to patients' medical histories can be of vital importance to ensure proper treatment in an emergency. Germany is planning to introduce a medical emergency dataset (MED), accessible through an electronic health card, and comprising important patient information, such as diagnoses, medications, and allergies. Introduction: This article evaluates the effect of MEDs on the comprehensiveness of a physician's documentation and handover process to the emergency department of a hospital. Materials and Methods: In 2 randomized, crossover simulation studies, 72 emergency physicians participated in 2 emergency scenarios, either with or without access to an MED. Subsequently, they had to document the key information (pre-existing conditions, medications, and allergies) and hand it over to a fictional hospital. The influence of the MED on the documentation of key information was analyzed using the two-sided Prescott's exact test. Sensitivity analyses adjusting for scenario were conducted. Results: The results show that in scenarios with an MED, documentation of key information in the handover process was more complete. In the first trial, 2 of 3 key items (pre-existing conditions/information and allergies) presented a statistically noticeable difference in scenarios with the MED. The second trial confirmed these results for all key items. Discussion: The findings indicate that the use of MEDs in emergency care could be beneficial since documentation and handover in scenarios with an MED were superior to current real-world practices. Conclusions: Access to more complete patient information through an MED could help to improve the patient's treatment.

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.

Telemedicine and Distance Learning for Obstetrician/Gynecologist Provider Education

Tele-education is the use of communications technologies to distribute knowledge from one health care provider to another when distance separates providers. At the University of Arkansas for Medical Sciences, tele-education has been used for more than two decades to educate and support rural obstetrician/gynecologists throughout the state. Tele-education at University of Arkansas for Medical Sciences incorporates numerous interactive videoconferences and other digital portals and platforms. Continued provider education through tele-education increases access to quality care and evidenced-based practices for rural populations and is an effective strategy in the battle against health care disparities.

Does Telemedical Support of First Responders Improve Guideline Adherence in an Offshore Emergency Scenario? A Simulator-Based Prospective Study

OBJECTIVE

To investigate, in a simulator-based prospective study, whether telemedical support improves quality of emergency first response (performance) by medical non-professionals to being non-inferior to medical professionals.

SETTING

In a simulated offshore wind power plant, duos (teams) of offshore engineers and teams of paramedics conducted the primary survey of a simulated patient.

PARTICIPANTS

38 offshore engineers and 34 paramedics were recruited by the general email invitation.

INTERVENTION

Teams (randomised by lot) were supported by transmission technology and a remote emergency physician in Berlin.

OUTCOME MEASURES

From video recordings, performance (17 item checklist) and required time (up to 15 min) were quantified by expert rating for analysis. Differences were analysed using two-sided exact Mann-Whitney U tests for independent measures, non-inferiority was analysed using Schuirmann one-sided test. The significance level of 5 % was Holm-Bonferroni adjusted in each family of pairwise comparisons.

RESULTS

Nine teams of engineers with, nine without, nine teams of paramedics with and eight without support completed the task. Two experts quantified endpoints, insights into rater dependence were gained. Supported engineers outperformed unsupported engineers (p<0.01), insufficient evidence was found for paramedics (p=0.11). Without support, paramedics outperformed engineers (p<0.01). Supported engineers' performance was non-inferior (at one item margin) to that by unsupported paramedics (p=0.03). Supported groups were slower than unsupported groups (p<0.01).

CONCLUSIONS

First response to medical emergencies in offshore wind farms with substantially delayed professional care may be improved by telemedical support. Future work should test our result during additional scenarios and explore interdisciplinary and ecosystem aspects of this support.

TRIAL REGISTRATION NUMBER

DRKS00014372.

Research challenges in prehospital care: the need for a simulation-based prehospital research laboratory

There is a need for improved research in the field of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. The present paper argues for the potential of simulation for prehospital research, e.g., through the development of an advanced simulation-based prehospital research laboratory. However, the prehospital context is different from other healthcare areas, which implies special requirements for the design of this type of laboratory, in terms of simulation width (including the entire prehospital work process) and depth (level of scenario detail). A set of features pertaining to simulation width, scenario depth, equipment, and personnel and competence are proposed. Close tailoring between these features and the prehospital research problems and context presents great potential to improve and further prehospital research.

Régulation médicale : mise au point 2018 et développements futurs

En 2018, les centrales de régulation d’urgences médicales devraient toutes être en mesure d’offrir certaines plus-values essentielles aux patients : une réanimation par téléphone avec accompagnement des témoins jusqu’à l’arrivée des secours, l’utilisation de réseaux de premiers répondants, ainsi que les défibrillateurs automatiques des domaines privés et publics via des applications Internet, l’assistance aux témoins pour réaliser des injections d’épinéphrine lors de réactions allergiques sévères ou de chlorhydrate de glucagon lors d’hypoglycémie. En complément, le bénéfice attendu des centrales d’urgences médicales visà-vis du système de soins dans son ensemble implique une meilleure efficience quant à l’engagement des moyens dont elles disposent. Cela ne peut se faire qu’en collectant les données liées à l’engagement des moyens (type, nombre, niveau de priorité) et en les corrélant avec la gravité de la situation observée sur site par les intervenants. Cette analyse permet d’estimer les taux de sur-triage et de sous-triage de la centrale lors de la décision d’envoi des moyens. L’utilisation appropriée des signaux prioritaires qui en découle permet également de réduire les risques des intervenants et de la population générale. Finalement, les fusions de centrales permettent de rationaliser certains coûts fixes, de faire face à des difficultés de recrutement et de formation, mais également d’augmenter la qualité de la régulation offerte à la population.

Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians

Background: Tension pneumothorax is a frequent cause of potentially preventable death. Tube thoracostomy (TT) can obviate death but is invasive and fraught with complications even in experienced hands. We assessed the utility of a remote international virtual network (RIVN) of specialized mentors to remotely guide military medical technicians (medics) using wireless informatics. Methods: Medics were randomized to insert TT in training mannequins (TraumaMan; Abacus ALS, Meadowbrook, Australia) supervised by RIVN or not. The RIVN consisted of trauma surgeons in Canada and Australia and a senior medic in Ohio. Medics wore a helmet-mounted wireless camera with laser pointer to confirm anatomy and two-way voice communication using commercial software (Skype^®). Performance was measured through objective task completion (pass/fail) regarding safety during the procedure, proper location, and secure anchoring of the tube, in addition to remote mentor opinion and subjective debrief. Results: Fourteen medics attempted TT, seven mentored and seven not. The RIVN was functional and surgeons on either side of the globe had real-time communication with the mentees. TT placement was considered safe, successful, and secure in 100% of mentored (n = 7) procedures, although two (29%) received corrective remote guidance. All (100%) of the unmentored attempted and adequately secured the TT and were safe. However, only 71% (n = 5) completed the task successfully (p = 0.46). Participating medics subjectively felt remote telementoring (RTM) increased self-confidence (strong agreement mean 5/5 ± 0); confidence to perform field TT (agreement (4/5 ± 1); and decreased anxiety (strong agreement 5/5 ± 1). Subjectively, the remote mentors felt in 100% of the mentored procedures that "yes" they were able to assist the medics (1.86 ± 0.38), and in 71% (n = 5) felt "yes" they made TT safer (2.29 ± 0.49). Conclusions: RTM descriptively increased the success of TT placement and allowed for real-time troubleshooting from thousands of kilometers with a redundant capability. RTM was subjectively associated with high levels of satisfaction and self-reported self-confidence. Continued controlled and critical evaluation and refinement of telemedical techniques should continue. Trial Registration: ID ISRCTN/77929274.

The Impact of Telemedicine on Teamwork and Workload in Pediatric Resuscitation: A Simulation-Based, Randomized Controlled Study

BACKGROUND

Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described.

OBJECTIVES

To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation.

METHODS

Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively.

RESULTS

Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020).

CONCLUSIONS

In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.

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.

Interdisciplinary eHealth for the care of people living with traumatic brain injury: A systematic review

OBJECTIVE

To identify literature which discusses the barriers and enablers of eHealth technology and which evaluates its role in facilitating interdisciplinary team work for the care of people with a traumatic brain injury (TBI).

DESIGN

Systematic review.

DATA SOURCES

Studies were identified by searching CINAHL, Embase, Medline, PsycINFO, Scopus, and Web of Science.

STUDY SELECTION

Studies included in the review were required to feature an eHealth intervention which assisted interdisciplinary care for people with TBI.

DATA EXTRACTION

Descriptive data for each study described the eHealth intervention, interdisciplinary team, outcomes, and barriers and facilitators in implementing eHealth interventions.

RESULTS

The search resulted in 1389 publications, of which 35 were retrieved and scanned in full. Six studies met all the inclusion criteria for the review. Four different eHealth interventions were identified: (i) an electronic goals systems, (ii) telerehabilitation, (iii) videoconferencing, and (iv) a point-of-care team-based information system. Various barriers and facilitators were identified in the use of eHealth.

CONCLUSION

eHealth interventions have been reported to support interdisciplinary teams for the care of TBI. However, there is a substantial gap in existing literature regarding the barriers and enablers which characterize a successful interdisciplinary eHealth model for people with TBI.

A systematic review of prehospital telehealth utilization

Objective There has been moderate evidence of telehealth utilization in the field of emergency medicine, but less is known about telehealth in prehospital emergency medical services (EMS). The objective of this study is to explore the extent, focus, and utilization of telehealth for prehospital emergency care through the analysis of published research. Methods The authors conducted a systematic literature review by extracting data from multiple research databases (including MEDLINE/PubMed, CINAHL Complete, and Google Scholar) published since 2000. We used consistent key search terms to identify clinical interventions and feasibility studies involving telehealth and EMS, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results We identified 68 articles focused specifically on telehealth interventions in prehospital care. The majority (54%) of the studies involved stroke and acute cardiovascular care, while only 7% of these (4) focused on telehealth for primary care. The two most common delivery methods were real-time video-conferencing capabilities (38%) and store and forward (25%); and this variation was based upon the clinical focus. There has been a significant and positive trend towards greater telehealth utilization. European telehealth programs were most common (51% of the studies), while 38% were from the United States. Discussion and Conclusions Despite positive trends, telehealth utilization in prehospital emergency care is fairly limited given the sheer number of EMS agencies worldwide. The results of this study suggest there are significant opportunities for wider diffusion in prehospital care. Future work should examine barriers and incentives for telehealth adoption in EMS.

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).

Telemedicine Applications for the Pediatric Emergency Medicine: A Review of the Current Literature

OBJECTIVE

The aim of this study was to review current literature relating to telemedicine in pediatric emergency medicine including its clinical applications and challenges associated with its implementation.

METHODS

We reviewed the literature using standard search methods in accordance with preferred reporting items for systematic reviews and meta-analysis. We included the studies done in emergency settings for all age groups and narrowed our search to the articles that are relevant to "impact on quality of care" and "patient outcome." We also described current telemedicine uses, software, hardware, and other requirements needed for pediatric emergency applications.

RESULTS

Telemedicine has a potential role in pediatric emergency medicine for real-time decision making to improve quality of care for children. Logistic and legal challenges exist for pediatric emergency medicine applications similar to its uses in other settings.

CONCLUSIONS

Current frameworks exist in the use of telemedicine for pediatric emergency medicine. Research is still needed to see whether clinical outcomes are improved with pediatric emergency telemedicine solutions. Practical issues regarding training, accessibility, and resource allocation should be explored as pediatric emergency telemedicine evolves.

[Potential and effectiveness of a telemedical rescue assistance system. Prospective observational study on implementation in emergency medicine]

BACKGROUND

The demographic change and an increasing multimorbidity of patients represent increasing challenges for the adequate prehospital treatment of emergency patients. The incorporation of supplementary telemedical concepts and systems can lead to an improved guideline-conform treatment. Beneficial evidence of telemedical procedures is only known for isolated disease patterns; however, no mobile telemedical concept exists which is suitable for use in the wide variety of different clinical situations.

AIM

This article presents a newly developed and evaluated total telemedical concept (TemRas) that encompasses organizational, medical and technical components. The use of intelligent and robust communication technology and the implementation of this add-on system allows the telemedical support of the rescue service for all emergencies.

METHODS

After development of the telemedical rescue assistance system, which includes organizational, medical and technical components, a telemedical centre and six ambulances in five different districts in North-Rhine Westphalia were equipped with this new tool. During the evaluation phase of 1 year in the routine emergency medical service the rate of complications as well as differences between urban and rural areas were analyzed with respect to different target parameters.

RESULTS

Between August 2012 and July 2013 a total of 401 teleconsultations were performed during emergency missions and 24 during secondary interhospital transfers. No complications due to teleconsultation were observed. The mean duration (±SD) of teleconsultations was longer in rural areas than in urban areas with 28.6±12.0 min vs. 25.5±11.1 min (p < 0.0001). In 63.2% of these missions administration of medications was delegated to the ambulance personnel (52.0% urban vs. 73.6% rural, p < 0.0001). The severity of ailments corresponded to scores of III and VI in the National Advisory Committee for Aeronautics (NACA) classification.

CONCLUSION

Emergency medical care of patients with support by a telemedical system is technically feasible, safe for the patient and allows medical treatment independent of spatial availability of a physician in different emergency situations.

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.

Mapping the use of simulation in prehospital care - a literature review

Background

High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice.

Methods

An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context.

Results

The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage.

Conclusion

Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of prehospital care, which this review reveals, includes inadequate skills of prehospital staff regarding ventilation and CPR, on both children and adults, the lack of skills in paediatric resuscitation and the lack of knowledge in assessing and managing burns victims. These circumstances suggest critical areas for further training and research, at both local and global levels.

Comparison of physician staffed emergency teams with paramedic teams assisted by telemedicine--a randomized, controlled simulation study

PURPOSE AND BACKGROUND

Emergency medical services (EMSs) vary considerably. While some are physician staffed, most systems are run by paramedics. The objective of this randomized, controlled simulation study was to compare the emergency care between physician staffed EMS teams (control group) and paramedic teams that were supported telemedically by an EMS physician (telemedicine group).

METHODS

Overall 16 teams (1 EMS physician, 2 paramedics) were randomized to the control group or the telemedicine group. Telemedical functionalities included two-way audio communication, transmission of vital data (numerical values and curves) and video streaming from the scenario room to the remotely located EMS physician. After a run-in scenario all teams completed four standardized scenarios, in which no highly invasive procedures (e.g. thoracic drain) were required, two using high-fidelity simulation (burn trauma, intoxication) and two using standardized patients (renal colic, barotrauma). All scenarios were videotaped and analyzed by two investigators using predefined scoring items.

RESULTS

Non case-specific items (31 vs. 31 scenarios): obtaining of 'symptoms', 'past medical history' and 'events' were carried out comparably, but in the telemedicine group 'allergies' (17 vs. 28, OR 7.69, CI 2.1-27.9, p=0.002) and 'medications' (17 vs. 27, OR 5.55, CI 1.7-18.0, p=0.004) were inquired more frequently. No significant differences were found regarding the case-specific items and in both groups no potentially dangerous mistreatments were observed.

CONCLUSION

Telemedically assisted paramedic care was feasible and at least not inferior compared to standard EMS teams with a physician on-scene in these scenarios.