Elsevier

Resuscitation

Volume 83, Issue 5, May 2012, Pages 626-632
Resuscitation

Simulation and education
Teleconsultation in pre-hospital emergency medical services: Real-time telemedical support in a prospective controlled simulation study,☆☆

https://doi.org/10.1016/j.resuscitation.2011.10.029Get rights and content

Abstract

Background

Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible.

In preparation for bringing such a system into practice within the research project “Med-on-@ix”, a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing.

Material and methods

In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario.

Results

Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p = 0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p = 0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p = 0.0421); synchronized shock (6/14 vs. 14/15; p = 0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p = 0.0092); mean time to inform trauma centre 547 vs. 189 s (p = 0.0001). No significant impairment of performance was detected in TMA groups.

Conclusions

In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.

Introduction

Requirements and costs for Emergency Medical Services (EMS) are increasing in the USA and Europe. A rising number of emergency calls with an increasing proportion of Advanced Life Support (ALS) responses, and furthermore a high percentage of unnecessary missions are challenging circumstances for the future.1, 2, 3, 4 The implementation of telemedicine in EMS may offer a solution to tackle these challenges. As personal life is affected by the use of smartphones and mobile internet, the use and evaluation of these technologies concerning EMS remains limited. Although technological opportunities abound, minimal applications have been established in clinical practice: promising approaches, especially 12-lead-ECG transmission, had beneficial effects.5, 6, 7 However, ambitious projects to implement e-health systems into EMS have failed8 and widespread use of telemetry remains uncommon. Therefore, experts of the American Heart Association (AHA) have recommended further research into ECG data transfer and data acquisition, as well as into the establishment of quality improvement systems.9 These challenges are accompanied by a soaring shortage of physicians throughout the western world, particularly in rural areas.10, 11

The joint research project “Med-on-@ix”12 is conducted to design a telemedicine system for transmission of all relevant information from the scene (e.g. vital parameters, 12-lead-ECG, video and audio) in real-time to a centre staffed with highly trained EMS physicians that offer telemedical assistance (TMA).

With support from the German Federal Ministry of Economics and Technology, a consortium was assembled that brings in the expertise of all relevant fields involved including the telecommunication and monitoring industries, medical and technological research stakeholders, legal scientists, and various end-users (further information: www.medonaix.de).

“Med-on-@ix” generates a telemedicine system for EMS that ensures secure, reliable and mobile data transmission from the scene to a specialized consultation centre staffed with experienced EMS physicians to enable TMA. Therefore, extensive research on this system including the use of both simulator- and field-testing studies has to be performed in the German EMS systems prior to its implementation into clinical routine.

Against this background, the described simulation study was conducted as a required step to investigate whether TMA has a positive impact on the quality of care in EMS. Irrespective of the possible benefit of such a system for the support of non-physician providers, especially in rural areas, we decided to look first at the effects regarding quality of treatment that this system might offer as an “add-on” in German physician-staffed response units. We analyzed the impact at predefined time intervals in terms of different diagnostic and therapeutic operations as well as compliance with current guidelines. Moreover, general experiences using the nascent system were observed.

Section snippets

Study design and preparation

For this prospective controlled simulation study two standardized case scenarios were designed by an expert committee. ST-segment elevation myocardial infarction (STEMI) and major trauma with traumatic brain injury (MT) were chosen as scenarios (Fig. 1), because established guidelines have been published for both.13, 14, 15, 16 Scoring items were developed for each scenario representing guideline-based diagnostic and therapeutic skills required in pre-hospital emergency care (see first column

Participants and descriptive data

87 subjects in 29 EMS teams took part in the study: 29 EMS physicians (38% female; age 36.6 ± 6.9 years, range 28–61; professional experiences in EMS: 3.4 ± 3.4 years) and 58 paramedics (22.4% female, age 30.9 ± 7.4 years, range 21–50; professional experiences in EMS: 8.8 ± 6.1 years).

STEMI scenario

Table 1 summarizes the results The following events could be observed in addition: all teams used 12-lead-ECG but one team without TMA did not identify ST-elevations, diagnosed the patient with pulmonary embolism and

Discussion

In this first study using the functionality of combined telemedical applications and real-time teleconsultation for EMS, the objective was to evaluate the performance without and with TMA. Use of this system resulted in improved quality of treatment with respect to adherence to current guidelines and avoidance of all potentially life-threatening therapeutic approaches. Regarding time requirements, both groups had at least comparable mean values in most measured intervals, although consultation

Conclusions

Telemedical assistance was able to improve treatment and safety by closer adherence to current guidelines. This study bares the potential for further research focussing on methods and technical improvement to utilise the opportunities of teleconsultation in critical care situations especially pre-hospital.

Funding sources and disclosures

The study was conducted within the joint research project “Med-on-@ix” funded by the German Federal Ministry of Economics and Technology (BMWi), Project-No.: 01MB07022. Philips Healthcare (Hamburg, Germany) provided the monitoring devices (Heartstart MRx) and the IntelliVue Information Centre Software. Philips Healthcare had no influence on the design of the study protocol or interpretation of gathered data.

Conflict of interest statement

All authors confirm that neither governmental nor industrial financial support that could influence the work was granted to them.

Acknowledgments

The authors would like to thank all participants for taking part voluntarily in this study and M. Brandt, MD, R. Döring, O. Grottke, MD, MPH, V. Miklosch, MD, and especially B. Siegers, MD for their support. Additionally, we appreciate the outstanding engagement and support for video-documentation as well as the work on the content management system of the video data, especially F. Schenkat, P. Aretz, U. Heuter, U. Malchus, and A. Czepluch.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.10.029.

    ☆☆

    Parts of the results were presented at the annual meeting of the German Interdisciplinary Society for Intensive Care and Emergency Medicine (DIVI) 2008, Hamburg, Germany and at the fifth annual meeting of the German research groups in emergency medical care 2009, Kiel, Germany, Notfall & Rettungsmedizin, Suppl. 1, 2009: WATN 09-29 and at the Resuscitation Science Symposium 2009 of the American Heart Association, Orlando, USA.

    d

    On behalf of the Med-on-@ix-Working Group (in addition to listed authors): M. Brandt; T. Brodziak; R. Döring; O. Grottke; C. Hermanns; H. Fischermann; M. Müller; V. Miklosch; I. Na; S. Schroeder; M.-T. Schneiders; B. Siegers; M. Tobias; D. Wielpütz.

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