J.C. Brokmann

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.

Improved technical performance of a multifunctional prehospital telemedicine system between the research phase and the routine use phase – an observational study

Introduction Telemedical concepts in emergency medical services (EMS) lead to improved process times and patient outcomes, but their technical performance has thus far been insufficient; nevertheless, the concept was transferred into EMS routine care in Aachen, Germany. This study evaluated the system’s technical performance and compared it to a precursor system. Methods The telemedicine system was implemented on seven ambulances and a teleconsultation centre staffed with experienced EMS physicians was established in April 2014. Telemedical applications included mobile vital data, 12-lead, picture transmission and video streaming from inside the ambulances. The tele-EMS physician filled in a questionnaire regarding the technical performance of the applications, background noise and assessed clinical values of the transmitted pictures and videos after each mission between 15 May 2014–15 October 2014. Results Teleconsultation was established during 539 emergency cases. In 83% of the cases (n = 447), only the paramedics and the tele-EMS physician were involved. Transmission success rates ranged from 98% (audio connection) to 93% (12-lead electrocardiogram (ECG) transmission). All functionalities, except video transmission, were significantly better than the pilot project (p < 0.05). Severe background noise was detected to a lesser extent (p = 0.0004) and the clinical value of the pictures and videos were considered significantly more valuable. Discussion The multifunctional system is now sufficient for routine use and is the most reliable mobile emergency telemedicine system compared to other published projects. Dropouts were due to user errors and network coverage problems. These findings enable widespread use of this system in the future, reducing the critical time intervals until medical therapy is started.

Analgesia by telemedically supported paramedics compared with physician-administered analgesia: A prospective, interventional, multicentre trial.

In German emergency medical services (EMS), the analgesia is restricted to physicians. In this prospective, interventional, multicentre trial, complications with and quality of telemedically delegated analgesia were evaluated.

Potenzial und Wirksamkeit eines telemedizinischen Rettungsassistenzsystems

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.

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

There is a need for new strategies to face current and future problems in German Emergency Medical Services (EMS). Lack of quality management and increasing costs in the presence of a deficit of EMS physicians are typical challenges, resulting in an increasing deficit in medical care. In addition, information and communication technology used in German EMS is out of date. The physician-powered EMS has to be modernized to increase quality and show measurable evidence of its effectiveness. Otherwise its future existence is at serious risk. Therefore, the project Med-on-@ix was created by the Department of Anaesthesiology at the University Hospital Aachen, Germany. The aim was to develop a new emergency telemedicine service system and to implement it clinically in order to advance medical care and effectiveness in the EMS by process optimization of each scene call. This system offers EMS physicians and paramedics an additional consultation by a specialised centre of competence, thus assuring medical therapy according to evidence-based guidelines. Several prospective studies are conducted to analyse this system in comparison to the conventional EMS.ZusammenfassungEs bedarf neuer Konzepte, um bestehenden und zukünftigen Problemen im Rettungsdienst zu begegnen. Mangelndes Qualitätsmanagement bei steigendem Kostendruck und zunehmendem (Not-)Ärztemangel kann zu messbaren Defiziten in der Notfallversorgung führen. Zudem wird derzeit eine veraltete Informationstechnik eingesetzt. Das Notarztsystem muss einerseits eine Modernisierung und Qualitätssteigerung erfahren, andererseits sind deutlichere Nachweise der Leistungsfähigkeit vonnöten. Nur so kann eine hochwertige Patientenversorgung für die Zukunft gewährleistet werden. Vor diesem Hintergrund wurde die Projektidee Med-on-@ix in Aachen mit dem Ziel entwickelt, die Versorgungsqualität und die Einsatzeffizienz zu steigern. Hierzu wird ein umfassendes notfallmedizinisches Telemedizinsystem entwickelt, das Notärzten und Rettungsdienstpersonal eine zusätzliche Beratung durch ein Kompetenzzentrum bereitstellt. Die leitliniengerechte Behandlung soll dadurch unter direkter Qualitätskontrolle sichergestellt werden. Prospektive Studien am Simulator und im realen Einsatz evaluieren das System im Vergleich mit dem aktuellen Rettungssystem.AbstractThere is a need for new strategies to face current and future problems in German Emergency Medical Services (EMS). Lack of quality management and increasing costs in the presence of a deficit of EMS physicians are typical challenges, resulting in an increasing deficit in medical care. In addition, information and communication technology used in German EMS is out of date. The physician-powered EMS has to be modernized to increase quality and show measurable evidence of its effectiveness. Otherwise its future existence is at serious risk. Therefore, the project Med-on-@ix was created by the Department of Anaesthesiology at the University Hospital Aachen, Germany. The aim was to develop a new emergency telemedicine service system and to implement it clinically in order to advance medical care and effectiveness in the EMS by process optimization of each scene call. This system offers EMS physicians and paramedics an additional consultation by a specialised centre of competence, thus assuring medical therapy according to evidence-based guidelines. Several prospective studies are conducted to analyse this system in comparison to the conventional EMS.

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

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

Evidenzbasierte Medizin in der notfallmedizinischen Fort- und Weiterbildung

ZusammenfassungDer nachgewiesene Nutzen einzelner Maßnahmen hat in der präklinischen Notfallmedizin eine hohe Bedeutung und ist die Grundlage für eine patientenorientierte Versorgung. Ein Notarzt, der vor Ort den Patienten nach einer orientierenden Untersuchung zielgerichtet therapieren soll, muss eine gute Fort- und Weiterbildung genießen, in der sich dieser Nutzen widerspiegeln sollte.Betrachtet man im Zusammenhang mit der Weiterbildung zum Notarzt die Analysen im Rahmen eines Qualitätsmanagements und der Überprüfung von Standards, so zeigen unterschiedliche Untersuchungen Defizite des arztbesetzten Rettungsdienstes auf. Hier wird deutlich, dass es kaum eine medizinische Subdisziplin gibt, die derart von meinungsorientierten Handlungsanweisungen bestimmt wird, wie die prähospitale Notfallmedizin.Es müssen in den angebotenen Fort- und Weiterbildungen einheitliche Inhalte zu Maßnahmen und Therapien dargestellt werden, welche einer evidenzbasierten Medizin entsprechen. Das vorgestellte Konzept soll eine Optimierung der Weiterbildung von Notärzten darstellen und orientiert sich an den tatsächlichen Belangen der Teilnehmer.AbstractEvidence of benefits of specific procedures is fundamental in prehospital emergency medicine settings and is the basis for patient-oriented treatment. Emergency physicians involved in goal-directed therapy of critically ill patients on-site should rely on good continuing education reflecting this evidence, but in fact these demands are not consistently considered in postgraduate concepts for emergency medical care.Various studies have shown that analysis of the quality of management as well as assessing applied standards reveal deficits in the medical rescue service with respect to the education of emergency physicians. From this it becomes clear that there is hardly any other medical sub-discipline which is so dictated by subjective opinions as prehospital emergency medicine.This article focuses on possible approaches for optimizing the training of emergency physicians. In the future education and training concepts should provide uniform content regarding diagnosis and treatment strategies, which meet the criteria of evidence-based medicine.

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.

Potenzial und Wirksamkeit eines telemedizinischen Rettungsassistenzsystems : Prospektive observationelle Studie zum Einsatz in der Notfallmedizin

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.

Airway and ventilator management in trauma patients.

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