Treatment of Acute Coronary Syndrome by Telemedically Supported Paramedics Compared With Physician-Based Treatment: A Prospective, Interventional, Multicenter Trial

[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.

Long-term effects of a prehospital telemedicine system on structural and process quality indicators of an emergency medical service

The benefits of a telemedical support system for prehospital emergency medical services include high-level emergency medical support at the push of a button: delegation of drug administration, diagnostic assistance, initiation of therapeutic measures, or choice of hospital destination. At various European EMS sites telemedical routine systems are shortly before implementation. The aim of this study was to investigate the long-term effects of implementing a tele-EMS system on the structural and procedural quality indicators and therefore performance of an entire EMS system. This retrospective study included all EMS missions in Aachen city between 2015 and 2021. Regarding structural indicators of the EMS system, we investigated the overall number of emergency missions with tele-EMS and onsite EMS physicians. Furthermore, we analyzed the distribution of tracer diagnosis and process quality with respect to the time spans on the scene, time until teleconsultation, duration of teleconsultation, prehospital engagement time, and number of simultaneous teleconsultations. During the 7-year study period, 229,384 EMS missions were completed. From 2015 to 2021, the total number of EMS missions increased by 8.5%. A tele-EMS physician was consulted on 23,172 (10.1%) missions. The proportion of telemedicine missions increased from 8.6% in 2015 to 12.9% in 2021. Teleconsultations for missions with tracer diagnoses decreased during from 43.7% to 30.7%, and the proportion of non-tracer diagnoses increased from 56.3% to 69.3%. The call duration for teleconsultation decreased from 12.07 min in 2015 to 9.42 min in 2021. For every fourth mission, one or more simultaneous teleconsultations were conducted by the tele-EMS physician on duty. The implementation and routine use of a tele-EMS system increased the availability of onsite EMS physicians and enabled immediate onsite support for paramedics. Parallel teleconsultations, reduction in call duration, and increase in ambulatory onsite treatments over the years demonstrate the increasing experience of paramedics and tele-EMS physicians with the system in place. A prehospital tele-EMS system is important for mitigating the current challenges in the prehospital emergency care sector.

[Update tele-emergency medicine : Status quo and perspectives]

CURRENT STATUS OF EMERGENCY MEDICINE IN GERMANY

Increasing numbers of rescue missions in recent years have led to a growing staff shortage of paramedics as well as physicians in the emergency medical system (EMS) with an urgent need for optimized usage of resources. One option is the implementation of a tele-EMS physician system, which has been established in the EMS of the City of Aachen since 2014.

IMPLEMENTATION OF TELE-EMERGENCY MEDICINE

In addition to pilot projects, political decisions lead to the introduction of tele-emergency medicine. The expansion is currently progressing in various federal states, and a comprehensive introduction has been decided for North Rhine-Westphalia and Bavaria. The adaptation of the EMS physician catalog of indications is essential for the integration of a tele-EMS physician.

STATUS QUO OF TELE-EMERGENCY MEDICINE

The tele-EMS physician offers the possibility of a long-term and comprehensive EMS physician expertise in the EMS regardless of location and, therefore, to partially compensate for a lack of EMS physicians. Tele-EMS physicians can also support the dispatch center in an advisory capacity and, for example, clarify secondary transport. A uniform qualification curriculum for tele-EMS physicians was introduced by the North Rhine and Westphalia-Lippe Medical Associations.

OUTLOOK

In addition to consultations from emergency missions, tele-emergency medicine can also be used for innovative educational applications, for example, in the supervision of young physicians or recertification of EMS staff. A lack of ambulances could be compensated for by a community emergency paramedic, who could also be connected to the tele-EMS physician.

Mobile Integrated Health Interventions for Older Adults: A Systematic Review

Background and Objectives

Mobile integrated health (MIH) interventions have not been well described in older adult populations. The objective of this systematic review was to evaluate the characteristics and effectiveness of MIH programs on health-related outcomes among older adults.

Research Design and Methods

We searched Ovid MEDLINE, Ovid EMBASE, CINAHL, AgeLine, Social Work Abstracts, and The Cochrane Library through June 2021 for randomized controlled trials or cohort studies evaluating MIH among adults aged 65 and older in the general community. Studies were screened for eligibility against predefined inclusion/exclusion criteria. Using at least 2 independent reviewers, quality was appraised using the Downs and Black checklist and study characteristics and findings were synthesized and evaluated for potential bias.

Results

Screening of 2,160 records identified 15 studies. The mean age of participants was 67 years. The MIH interventions varied in their focus, community paramedic training, types of assessments and interventions delivered, physician oversight, use of telemedicine, and post-visit follow-up. Studies reported significant reductions in emergency call volume (5 studies) and immediate emergency department (ED) transports (3 studies). The 3 studies examining subsequent ED visits and 4 studies examining readmission rates reported mixed results. Studies reported low adverse event rates (5 studies), high patient and provider satisfaction (5 studies), and costs equivalent to or less than usual paramedic care (3 studies).

Discussion and Implications

There is wide variability in MIH provider training, program coordination, and quality-based metrics, creating heterogeneity that make definitive conclusions challenging. Nonetheless, studies suggest MIH reduces emergency call volume and ED transport rates while improving patient experience and reducing overall health care costs.

Introduction of Telemedicine in a Prehospital Emergency Care Setting: A Pilot Study

Background

Advances in information and communication technology have led to telemedicine applications that could support paramedics in the prehospital field. In an effort to optimise the available resources like prehospital emergency physicians (PHP), the State Health Services of a Swiss state decided to launch a pilot study on the feasibility of using telemedicine in the prehospital emergency setting.

Objective

The primary objective was to measure the number of missions completed without technical problems with remote PHP support through telemedicine (tele-PHP). The secondary objectives were to evaluate the safety of this protocol and to describe the actions and decisions that clinicians can make by using tele-PHP.

Methods

This was a prospective observational pilot study on all missions involving the dispatch of ground PHP or tele-PHP. The severity score, dispatch criteria, actions, and decisions made by ground PHP and tele-PHP were collected.

Results

PHP were dispatched simultaneously with an ambulance on 478 occasions, including 68 (14%) situations that started directly with tele-PHP. Among those situations, three had to be transformed into on-site PHP missions after the on-site evaluation by paramedics. Fifteen missions were cancelled by paramedics once they were on site, and six missions encountered a connection issue. Forty-four PHP missions that were dispatched simultaneously with paramedics were completed by tele-PHP only without any connection problems. Paramedics and PHP estimated that actions or decisions were provided by PHP in 66% of the on-site PHP missions and 34% of the tele-PHP missions.

Conclusions

This is the first experience of tele-PHP regarding PHP dispatch in Switzerland. Despite the small number of missions carried out, tele-PHP could be used for well-selected situations to reduce the need for a PHP on site.

Optimizing an Emergency Medical Dispatch System to Improve Prehospital Diagnosis and Treatment of Acute Coronary Syndrome: Nationwide Retrospective Study in China

Background

Acute coronary syndrome (ACS) is the most time-sensitive acute cardiac event that requires rapid dispatching and response. The medical priority dispatch system (MPDS), one of the most extensively used types of emergency dispatch systems, is hypothesized to provide better-quality prehospital emergency treatment. However, few studies have revealed the impact of MPDS use on the process of ACS care.

Objective

This study aimed to investigate whether the use of MPDS was associated with higher prehospital diagnosis accuracy and shorter prehospital delay for patients with ACS transferred by an emergency medical service (EMS), using a national database in China.

Methods

This retrospective analysis was based on an integrated database of China’s MPDS and hospital registry. From January 1, 2016, to December 31, 2020, EMS-treated ACS cases were divided into before MPDS and after MPDS groups in accordance with the MPDS launch time at each EMS center. The primary outcomes included diagnosis consistency between hospital admission and discharge, and prehospital delay. Multivariable logistic regression and propensity score–matching analysis were performed to compare outcomes between the 2 groups for total ACS and subtypes.

Results

A total of 9806 ACS cases (3561 before MPDS and 6245 after MPDS) treated by 43 EMS centers were included. The overall diagnosis consistency of the after MPDS group (Cohen κ=0.918, P<.001) was higher than that of the before MPDS group (Cohen κ=0.889, P<.001). After the use of the MPDS, the call-to-EMS arrival time was shortened in the matched ACS cases (20.0 vs 16.0 min, P<.001; adjusted difference: –1.67, 95% CI –2.33 to –1.02; P<.001) and in the subtype of ST-elevation myocardial infarction (adjusted difference: –3.81, 95% CI –4.63 to –2.98, P<.001), while the EMS arrival-to-door time (20.0 vs 20.0 min, P=.31) was not significantly different in all ACS cases and subtypes.

Conclusions

The optimized use of MPDS in China was associated with increased diagnosis consistency and a reduced call-to-EMS arrival time among EMS-treated patients with ACS. An emergency medical dispatch system should be designed specifically to fit into different prehospital modes in the EMS system on a regional basis.

Telemedicine in medical education: An example of a digital preparatory course for the clinical traineeship - a pre-post comparison

Introduction: Telemedicine is a significant component of healthcare in most disciplines, giving great importance to the education of young physicians in this field. However, the topic of telemedicine has not yet been implemented in medical schools' curricula. This paper makes an important contribution to closing this gap by designing, implementing and evaluating a course with telemedical components. Using the example of a clinical traineeship preparation course, we investigated the extent to which integrated telemedical modules can contribute to the subjective confidence of students with regard to knowledge and confidence in performing practical telemedical skills, such as doctor-patient communication, taking medical histories, and applying handover techniques. Project description: The course evaluation was descriptive. Subjective confidence in clinical telemedicine skills was assessed before and after completion of the course using an online questionnaire and calculated in a pre-post design using Wilcoxon's signed-rank test. Results: The course was rated "very good" (31%) and "good" (54.2%) by the vast majority of students. The results of the Wilcoxon test show significant increases in students' feelings of confidence in performing practical telemedicine skills for all items. Discussion: This study shows that telemedicine modules integrated in a digital preparatory course contribute positively to students' subjective confidence in terms of knowledge and confidence in performing practical telemedicine skills. Specifically, this paper illustrates that professional digital doctor-patient communication, digital documentation of a medical history, and handoff techniques can be learned through telemedicine course content. Conclusion: Telemedicine modules increase students' subjective confidence in performing practical telemedicine skills. Practical telemedicine course content can thus reduce uncertainty in the use of telemedicine and prepare future physicians for its use.

[Is a tele-emergency physician system a sensible addition in rural German regions?-An analysis from a medical and economic perspective]

Hintergrund und Ziel

Um die präklinische Notfallversorgung zu optimieren und aktuelle Herausforderungen zu bewältigen, wurde im Landkreis Vorpommern-Greifswald im Jahr 2017 ein Telenotarzt-System eingeführt. Es sollte aus medizinischer und ökonomischer Sicht geprüft werden, ob dies, insbesondere im ländlichen Raum, eine effiziente Ergänzung der präklinischen Notfallversorgung darstellt.

Methodik

Es wurden ca. 250.000 Einsatzdaten, vor und nach Einführung des Systems, über die Jahre 2015 bis 2020 ausgewertet und ein Prä-Post-Vergleich über die Einsatzstruktur erstellt. Die 3611 Einsätze der Telenotärztinnen und -ärzte (TNA) wurden nach medizinischen Indikationen und zeitlichen Faktoren analysiert sowie mit Einsätzen ohne TNA verglichen. Zusätzlich erfolgten eine Analyse der Gesamtkosten des neuen Versorgungskonzeptes sowie eine Kostenanalyse der prä- und innerklinischen Behandlungskosten ausgewählter Erkrankungen.

Ergebnisse

Das Einsatzspektrum des TNA umfasste alle Altersstufen mit verschiedenen Meldebildern, die zu 48,2 % eine mittlere Erkrankungsschwere (stationäre Behandlung erforderlich) hatten. Von Patient*innen und Mitarbeitenden wurde das System gut angenommen. Die Einsatzdaten zeigten einen signifikanten Rückgang der Notarztbeteiligung bei telenotarztfähigen Einsatzfahrzeugen um 20 %. Die jährlichen Kosten des Systems belaufen sich auf ca. 1,7 Mio. €.

Schlussfolgerung

Die Ergebnisse belegen die Vorteilhaftigkeit des TNA-Systems, sodass es über die Projektdauer hinaus implementiert wurde. Das System ist medizinisch sinnvoll, funktionsfähig sowie effizient und steht als Innovation für die Umsetzung in ganz Deutschland bereit.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Tele-EMS physicians improve life-threatening conditions during prehospital emergency missions

Almost seven years ago, a telemedicine system was established as an additional component of the city of Aachen's emergency medical service (EMS). It allows paramedics to engage in an immediate consultation with an EMS physician at any time. The system is not meant to replace the EMS physician on the scene during life-threatening emergencies. The aim of this study was to analyze teleconsultations during life-threatening missions and evaluate whether they improve patient care. Telemedical EMS (tele-EMS) physician consultations that occurred over the course of four years were evaluated. Missions were classified as involving potentially life-threatening conditions based on at least one of the following criteria: documented patient severity score, life-threatening vital signs, the judgement of the onsite EMS physician involved in the mission, or definite life-threatening diagnoses. The proportion of vital signs indicating that the patient was in a life-threatening condition was analyzed as the primary outcome at the start and end of the tele-EMS consultation. The secondary outcome parameters were the administered drug doses, tracer diagnoses made by the onsite EMS physicians during the missions, and quality of the documentation of the missions. From January 2015 to December 2018, a total of 10,362 tele-EMS consultations occurred; in 4,293 (41.4%) of the missions, the patient was initially in a potentially life-threatening condition. Out of those, a total of 3,441 (80.2%) missions were performed without an EMS physician at the scene. Records of 2,007 patients revealed 2,234 life-threatening vital signs of which 1,465 (65.6%) were remedied during the teleconsultation. Significant improvement was detected for oxygen saturation, hypotonia, tachy- and bradycardia, vigilance states, and hypoglycemia. Teleconsultation during missions involving patients with life-threatening conditions can significantly improve those patients' vital signs. Many potentially life-threatening cases could be handled by a tele-EMS physician as they did not require any invasive interventions that needed to be performed by an onsite EMS physician. Diagnoses of myocardial infarction, cardiac pulmonary edema, or malignant dysrhythmias necessitate the presence of onsite EMS physicians. Even during missions involving patients with life-threatening conditions, teleconsultation was feasible and often accessed by the paramedics.

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.

[When emergency physician and tele-emergency physician save life together : A case description on the application of prehospital telemedicine for ventricular tachycardia with hemodynamic instability]

Telemedicine has already entered the rescue service in some regions of Germany. This case description is about a telemedical emergency physician case where an emergency doctor was also at the scene of the emergency. The patient had a life-threatening ventricular tachycardia and became hemodynamically unstable. The emergency physician was still inexperienced and overwhelmed by the complex situation. She decided to contact the tele-emergency medical services (tele-ems) and could then be instructed to perform intraosseous access, drug treatment and electrical cardioversion in the unstable patient. The cooperation with the tele-ems physician enabled the still inexperienced emergency physician to perform a guideline-compliant treatment and to transport the stabilized patient to the hospital in a timely manner.

Prehospital Diagnosis of Shortness of Breath Caused by Profound Metformin-Associated Metabolic Acidosis

Shortness of breath is a common complaint among patients in emergency medicine. While most common causes are usually promptly identified, less frequent aetiologies might be challenging to diagnose, especially in the pre-hospital setting. We report a case of prehospital dyspnoea initially ascribed to pulmonary oedema which turned out to be the result of profound metformin-associated metabolic acidosis. This diagnosis was already made during the prehospital phase by virtue of arterial blood gas measurement. Pre-hospital measurement of arterial blood gases is therefore feasible and can improve diagnostic accuracy in the field, thus avoiding unnecessary delay and potential harm to the patient before initiating the appropriate therapeutic actions.

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.

Employment of Telemedicine in Nursing Homes: Clinical Requirement Analysis, System Development and First Test Results

Purpose

Demographic change and lack of specialized workforces are challenging. Likewise, home visits by general practitioners (GPs) become rarer. If a nursing home resident develops acute symptoms, nurses are often inclined to call the rescue service. Besides patient-related consequences, this might lead to unnecessary hospitalization and far-reaching health economic costs. Due to legal restrictions of remote treatment in Germany, which were recently loosened, telemedicine is still in the early stages. The aim of this study was to employ a holistic telemedical system for nursing homes which facilitates the connection to a GP and thus avoids unnecessary hospitalizations in the case of ambulatory-sensitive illnesses.

Materials and Methods

After an inter-professional requirement analysis, the iterative development was started. In addition to an audio-video connection, several point of care measurements were integrated. Finally, first field tests were performed in a nursing home in a rural area in Germany.

Results

One nursing home was equipped with telemedical system based on the results of the requirement analysis and tele-medically connected to a GP. Over a period of seven months, 56 routine and emergency teleconsultations took place. Only one of those required a hospital admission. In addition to video telephony, electrocardiography and assessment of vitals such as pulse, blood pressure, oxygen saturation and auscultation of heart and lungs were applied frequently.

Conclusion

A telemedical system including integrated medical devices was successfully developed and has turned out to be helpful and even necessary for careful and reliable decision-making by the GP. First test results show high acceptance for elderly care. Involved patients, nurses, and the GP itemize various specific benefits, including economic, personal, and altruistic issues. Another issue that the current COVID-19 crisis brought to light is lowering the risk of contagion; GPs can replace their home visits by using telepresence combined with point of care measures.

A physician-staffed ground emergency medical service does not significantly shorten door-to-balloon time in patients with STEMI: an observational study in a single emergency center in Japan

Aim

Current guidelines recommend a door‐to‐balloon time (DTBT) of <90 min for reperfusion treatment of patients with ST‐segment elevation myocardial infarction (STEMI). A physician‐staffed ground emergency medical service (GEMS) using a rapid response car (RRC) system was implemented at our hospital in April 2015. The medical team, including a physician and nurse, is dispatched to assess the patient and expedite the start of treatment by emergency physicians and cardiologists after arrival at the hospital. The study aimed to determine whether the RRC system shortened the DTBT.

Methods

This retrospective observational study was carried out in a tertiary emergency center in Japan. Those STEMI patients with primary percutaneous intervention between January 2016 and December 2018 were evaluated. The DTBTs of patients transported by the RRC system, the emergency medical service (EMS), and transferred from other hospitals after STEMI diagnosis (TRANS group) were compared.

Results

A total of 121 patients were included, 33 in the RCC, 20 in the EMS, and 68 in the TRANS groups. The median DTBT was 51 min (interquartile range [IQR], 43–67) in the RRC, 61 min (IQR, 52–85) in the EMS, and 59 min (IQR, 48–72) in the TRANS groups (P = 0.13). The DTBT was not significantly shorter in the RRC than in the other groups.

Conclusion

An RRC physician‐staffed GEMS did not significantly shorten the DTBT of patients with STEMI compared with other transport systems.

Evaluation of a Rural Emergency Medical Service Project in Germany: Protocol for a Multimethod and Multiperspective Longitudinal Analysis

BACKGROUND

German emergency medical services are a 2-tiered system with paramedic-staffed ambulances as the primary response, supported by prehospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply, whereas the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of the essence because, with each passing minute, the chance of survival with good neurological outcome decreases.

OBJECTIVE

The project has 4 main objectives: (1) reduce the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (ie, bystander cardiopulmonary resuscitation), (2) provide faster professional first aid in addition to rescue services through alerting trained first aiders by mobile phone, (3) make more emergency physicians available more quickly through introducing the tele-emergency physician system, and (4) enhance emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services.

METHODS

We will evaluate project implementation in a tripartite prospective and intervention study. First, in medical evaluation, we will assess the influences of various project measures on quality of care using multiple methods. Second, the economic evaluation will mainly focus on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. Third, as part of the work and organizational analysis, we will assess important work- and occupational-related parameters, as well as network and regional indexes.

RESULTS

We started the project in 2017 and will complete enrollment in 2020. We finished the preanalysis phase in September 2018.

CONCLUSIONS

Overall, implementation of the project will entail realigning emergency medicine in rural areas and enhancing the quality of medical emergency care in the long term. We expect the project to lead to a measurable increase in medical laypersons' individual motivation to provide resuscitation, to strengthen resuscitation skills, and to result in medical laypersons providing first aid much more frequently. Furthermore, we intend the project to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via mobile phones. Previous projects in urban regions have shown that the tele-emergency physician system can provide a higher availability and quality of emergency call-outs in regular health care. We expect a closer interrelation of emergency practices of statutory health insurance physicians with the rescue service to lead to better coordination of rescue and on-call services.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14358.

Utilization, Safety, and Technical Performance of a Telemedicine System for Prehospital Emergency Care: Observational Study

Background

As a consequence of increasing emergency medical service (EMS) missions requiring an EMS physician on site, we had implemented a unique prehospital telemedical emergency service as a new structural component to the conventional physician-based EMS in Germany.

Objective

We sought to assess the utilization, safety, and technical performance of this telemedical emergency service.

Methods

We conducted a retrospective analysis of all primary emergency missions with telemedical consultation of an EMS physician in the City of Aachen (250,000 inhabitants) during the first 3 operational years of our tele-EMS system. Main outcome measures were the number of teleconsultations, number of complications, and number of transmission malfunctions during teleconsultations.

Results

The data of 6265 patients were analyzed. The number of teleconsultations increased during the run-in period of four quarters toward full routine operation from 152 to 420 missions per quarter. When fully operational, around the clock, and providing teleconsultations to 11 mobile ambulances, the number of teleconsultations further increased by 25.9 per quarter (95% CI 9.1-42.6; P=.009). Only 6 of 6265 patients (0.10%; 95% CI 0.04%-0.21%) experienced adverse events, all of them not inherent in the system of teleconsultations. Technical malfunctions of single transmission components occurred from as low as 0.3% (95% CI 0.2%-0.5%) during two-way voice communications to as high as 1.9% (95% CI 1.6%-2.3%) during real-time vital data transmissions. Complete system failures occurred in only 0.3% (95% CI 0.2%-0.6%) of all teleconsultations.

Conclusions

The Aachen prehospital EMS is a frequently used, safe, and technically reliable system to provide medical care for emergency patients without an EMS physician physically present. Noninferiority of the tele-EMS physician compared with an on-site EMS physician needs to be demonstrated in a randomized trial.

Technical Support by Smart Glasses During a Mass Casualty Incident: A Randomized Controlled Simulation Trial on Technically Assisted Triage and Telemedical App Use in Disaster Medicine

Background

To treat many patients despite lacking personnel resources, triage is important in disaster medicine. Various triage algorithms help but often are used incorrectly or not at all. One potential problem-solving approach is to support triage with Smart Glasses.

Objective

In this study, augmented reality was used to display a triage algorithm and telemedicine assistance was enabled to compare the duration and quality of triage with a conventional one.

Methods

A specific Android app was designed for use with Smart Glasses, which added information in terms of augmented reality with two different methods—through the display of a triage algorithm in data glasses and a telemedical connection to a senior emergency physician realized by the integrated camera. A scenario was created (ie, randomized simulation study) in which 31 paramedics carried out a triage of 12 patients in 3 groups as follows: without technical support (control group), with a triage algorithm display, and with telemedical contact.

Results

A total of 362 assessments were performed. The accuracy in the control group was only 58%, but the assessments were quicker (on average 16.6 seconds). In contrast, an accuracy of 92% (P=.04) was achieved when using technical support by displaying the triage algorithm. This triaging took an average of 37.0 seconds. The triage group wearing data glasses and being telemedically connected achieved 90% accuracy (P=.01) in 35.0 seconds.

Conclusions

Triage with data glasses required markedly more time. While only a tally was recorded in the control group, Smart Glasses led to digital capture of the triage results, which have many tactical advantages. We expect a high potential in the application of Smart Glasses in disaster scenarios when using telemedicine and augmented reality features to improve the quality of triage.

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.