Marc Felzen

Technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service – an observational study

We evaluated the technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service (EMS) from the users perspective. The telemedicine system was designed to transmit vital signs data and 12-lead-ECG data, send still pictures and allow voice communication and video transmission from an ambulance. The data were sent to a teleconsultation centre staffed with EMS physicians (tele-EMS physician). The system was used in 157 EMS missions. The applications were used successfully on 80% of missions for real-time vital signs transmission and on 97% for video transmission. The quality of the transmitted still images (n = 64) was: 23% excellent, 50% good, 17% moderate, 9% rather poor and 0% unusable. The quality of the video streaming (n = 36) was: 33% excellent, 56% good, 6% moderate, 6% rather poor and 0% unusable. The tele-EMS physician was able to assist the EMS team in several cases and provided the preliminary information for the hospital in nearly all missions. Use of the telemedical system in EMS is feasible and the quality of the transmitted images and video was satisfactory. However, technical reliability and availability need to be improved prior to routine use.

Acute and sustained effects of methylphenidate on cognition and presynaptic dopamine metabolism: an [18F]FDOPA PET study.

Methylphenidate (MPH) inhibits the reuptake of dopamine and noradrenaline. PET studies with MPH challenge show increased competition at postsynaptic D2/3-receptors, thus indirectly revealing presynaptic dopamine release. We used [18F]fluorodopamine ([18F]FDOPA)-PET in conjunction with the inlet–outlet model (IOM) of Kumakura et al. (2007) to investigate acute and long-term changes in dopamine synthesis capacity and turnover in nigrostriatal fibers of healthy subjects with MPH challenge. Twenty healthy human females underwent two dynamic [18F]FDOPA PET scans (124 min; slow bolus-injection; arterial blood sampling), with one scan in untreated baseline condition and the other after MPH administration (0.5 mg/kg, p.o.), in randomized order. Subjects underwent cognitive testing at each PET session. Time activity curves were obtained for ventral putamen and caudate and were analyzed according to the IOM to obtain the regional net-uptake of [18F]FDOPA (K; dopamine synthesis capacity) as well as the [18F]fluorodopamine washout rate (kloss, index of dopamine turnover). MPH substantially decreased kloss in putamen (−22%; p = 0.003). In the reversed treatment order group (MPH/no drug), K was increased by 18% at no drug follow-up. The magnitude of K at the no drug baseline correlated with cognitive parameters. Furthermore, individual kloss changes correlated with altered cognitive performance under MPH. [18F]FDOPA PET in combination with the IOM detects an MPH-evoked decrease in striatal dopamine turnover, in accordance with the known acute pharmacodynamics of MPH. Furthermore, the scan-ordering effect on K suggested that a single MPH challenge persistently increased striatal dopamine synthesis capacity. Attenuation of dopamine turnover by MPH is linked to enhanced cognitive performance in healthy females.

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.

The hip fracture surgery in elderly patients (HIPELD) study to evaluate xenon anaesthesia for the prevention of postoperative delirium: a multicentre, randomized clinical trial

Background: Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery. Methods: This was a phase II, multicentre, randomized, double‐blind, parallel‐group, controlled clinical trial conducted in hospitals in six European countries (September 2010 to October 2014). Elderly (≥75yr‐old) and mentally functional hip fracture patients were randomly assigned 1:1 to receive either xenon‐ or sevoflurane‐based general anaesthesia during surgery. The primary outcome was postoperative delirium diagnosed through postoperative day 4. Secondary outcomes were delirium diagnosed anytime after surgery, postoperative sequential organ failure assessment (SOFA) scores, and adverse events (AEs). Results: Of 256 enrolled patients, 124 were treated with xenon and 132 with sevoflurane. The incidence of delirium with xenon (9.7% [95% CI: 4.5 ‐14.9]) or with sevoflurane (13.6% [95% CI: 7.8 ‐19.5]) were not significantly different (P=0.33). Overall SOFA scores were significantly lower with xenon (least‐squares mean difference: −0.33 [95% CI: −0.60 to −0.06]; P=0.017). For xenon and sevoflurane, the incidence of serious AEs and fatal AEs was 8.0% vs 15.9% (P=0.05) and 0% vs 3.8% (P=0.06), respectively. Conclusions: Xenon anaesthesia did not significantly reduce the incidence of postoperative delirium after hip fracture surgery. Nevertheless, exploratory observations concerning postoperative SOFA‐scores, serious AEs, and deaths warrant further study of the potential benefits of xenon anaesthesia in elderly hip fracture surgery patients. Clinical trial registration: EudraCT 2009–017153–35; ClinicalTrials.gov NCT01199276.

Telemedizin: Potenziale in der Notfallmedizin

The telemedical support and networking between health personnel and medical specialists increases the quality of supply also in the prehospital emergency care. Till now only for some tracer diagnosis specifically designed telemedical services were used. However, now a unique holistic telemedicine system, which can be used for the whole emergency spectrum as a supplementary feature has been developed. It can be used for the whole prehospital emergency care. The needfulness and meaningfulness of telemedicine as well as the important structural characteristics in prehospital emergency care are pictured. The system, composed of hard- and software components (tele-physician working place, server infrastructure, mobile and in the ambulance fixed transmission box), ensures the availability of secure data transfer of speech, vital-parameters, photos, videostream, 12 lead ECG, etc.) in real-time. Base for a safe telemedicine application are the guidelines of the German Association of Anaesthesiology. Telemedicine systems are usable in different indications and disease manifestations. However, telemedicine also has limitations. Conclusion Telemedically assisted emergency missions can be managed safely, achieve a better quality in documentation and guideline conform therapy, reduce the medical binding time about more than 50 %, reduce physician escorting missions and show at least an equivalent quality of supply.

17 Sudden cardiac death: as sudden as commonly thought or do we know our patients before?

Aim About 100.000 people per year suffer from sudden cardiac death in Germany.1 In most of the cases (75%) this is cardiac-associated.2 According to this it appears to be probable that many patients did already have pre-existing cardiac diseases and might have been under medical treatment before. The aim of this study was to evaluate how many patients, who suffered from out-of-hospital cardiac arrest (OHCA), had documented diagnoses in the appropriate CA centre before. Method In this retrospective, observational study data was analysed based on the local documentation in the German Resuscitation Registry of the Emergency Medical Service of the city of Aachen. This data was matched with documentation of the local CA centre concerning pre-existing conditions and diagnoses for a five-year period (2012 to 2016). Results Overall 904 patients (Mean age 70±18 years) suffered from OHCA. Among these 41,9% (n=379) have been under medical treatment in the university hospital of Aachen during the last 3,7±4,5 years. 50,9% (n=193) of these had cardiopulmonary issues and 42,5% (n=161) were under medical treatment because of cardiac problems. Conclusion The analysis shows that more than 40% of these patients, who were resuscitated during the years of 2012 to 2016 have been known in the local CA centre before. This indicates that sudden cardiac death does not occur as sudden as commonly thought and that there is plenty of room to improve preventive programme, for example by awareness-raising or educational campaigns. References . Arntz HR, et al. Eur Heart J2000. . http://www.reanimationsregister.de/aktuelles.html Conflict of interest None Funding None

26 Systematic influences of the implementation of a comprehensive 24/7-telemedicine system into emergency medical service

Aim Demographic changes, decreasing availability of general practitioners, and at least regional shortage of qualified emergency medical service (EMS) physicians led to increasing arrival times and quality problems. Telemedical solutions could help to solve some of the problems. Methods Overall safety and feasibility of prehospital telemedically guided care was already proven in two research projects from 2007 to 2013.1–3 Their results led to implementation of a multifunctional mobile telemedicine system in the city of Aachen, Germany. From 04/2014 to 03/2015 all ambulances were equipped with a telemedicine system connected to a teleconsultation centre staffed with anesthesiologists experienced in emergency care. Audio, real-time vital data, 12-lead-ECG, picture transmission, and video streaming from ambulances was accomplished with encrypted and parallelized transmission using. Mission numbers prior and after implementation were compared to evaluate systematic influence. Results From 04/2014 to 06/2016 overall 4.901 EMS missions were supported and guided telemedically: n=4.151 emergency missions (85%) and n=750 (15%) inter-hospital transfers. Prior to implementation (04/2013–03/2014) 17.305 solely ambulance missions (68.7%) and 7.882 ambulance plus EMS physician unit missions were performed (31.3%). After implementation (04/2015–03/2016) 20.102 ambulance missions (76%) and 6.360 ambulance plus EMS physician missions (24%) were conducted which revealed a significant difference between both phases, p<0.0001. Conclusion The implementation of a telemedicine system into routine care led to a significant decrease in conventional on-scene physician missions as well as to an overall decrease in physician guided EMS cases. Therefore, the approach can be judged resource optimising and holds a potential for economic improvements although highly qualified physicians carry out the service. References Brokmann JC, Conrad C, Rossaint R, Bergrath S, Beckers SK, Tamm M, Czaplik M, Hirsch F. Treatment of acute coronary syndrome by telemedically supported paramedics compared with physician-based treatment of acute coronary syndrome: a prospective, interventional, multicentre trial. J Med Internet Res2016;18(12):e314doi:10.2196/jmir.6358 Felzen F, Brokmann JC, Beckers SK, Hirsch H, Tamm M, Rossaint R, Bergrath S. Technical performance of a multifunctional prehospital telemedicine system in routine emergency medical care – an observational study. Journal of Telemedicine and Telecare2016; pii: 1357633X16644115. Bergrath S, Reich A, Rossaint R, Rörtgen R, Gerber J, Fischermann H, Beckers SK, Brokmann JC, Schulz JB, Leber C, Fitzner C, Skorning M. Feasibility of Prehospital Teleconsultation in Acute Stroke – a pilot study in clinical routine. PLoS ONE2012;7(5):e36796. Conflict of interest None declared. Funding None declared.