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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.

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.

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.

Although prehospital emergency anesthesia (PHEA), with a specific focus on intubation attempts, is frequently studied in prehospital emergency care, there is a gap in the knowledge on aspects related to adherence to PHEA guidelines. This study investigates adherence to the “Guidelines for Prehospital Emergency Anesthesia in Adults” with regard to the induction of PHEA, including the decision making, rapid sequence induction, preoxygenation, standard monitoring, intubation attempts, adverse events, and administration of appropriate medications and their side effects. This retrospective study examined PHEA interventions from 01/01/2020 to 12/31/2021 in the city of Aachen, Germany. The inclusion criteria were adult patients who met the indication criteria for the PHEA. Data were obtained from emergency medical protocols. A total of 127 patients were included in this study. All the patients met the PHEA indication criteria. Despite having a valid indication, 29 patients did not receive the PHEA. 98 patients were endotracheally intubated. For these patients, monitoring had conformed to the guidelines. The medications were used according to the guidelines. A significant increase in oxygen saturation was reported after anesthesia induction (p < 0.001). The patients were successfully intubated endotracheally on the third attempt. Guideline adherence was maintained in terms of execution of PHEA, rapid sequence induction, preoxygenation, monitoring, selection, and administration of relevant medications. Emergency physicians demonstrated the capacity to effectively respond to cardiorespiratory events. Further investigations are needed on the group of patients who did not receive PHEA despite meeting the criteria. The underlying causes of decision making in these cases need to be evaluated in the future.

Video-assisted dispatcher support in cardiopulmonary resuscitation (VA-CPR) has shown beneficial effects on CPR quality. This study examines the influence of professional background on the ability to identify typical errors in CPR performance using video-based assessments. Within this simulation-based observational study, 61 participants (31 EMS personnel, 30 emergency physicians) evaluated nine video sequences showing simulated CPR or ventilation. Participants were grouped by profession, not randomly. The primary endpoint was the correct identification of expert-defined errors in the presented videos, analyzed in relation to professional background. Evaluation accuracy for CPR and ventilation videos was examined in relation to participant characteristics. Overall, n  = 427 CPR videos were correctly classified in 73.3% of cases by EMS personnel and 75.7% by emergency physicians (β = 0.370, SE = 0.297, 95% CI: −0.21 to 0.95, p  = 0.213). Ventilation scenarios ( n  = 122) were correctly classified in 93.5% (EMS) and 98.3%, (EP) (β = 4.50, SE = 6.73, 95% CI: −8.82 to 17.82, p  = 0.505). The models assessing classification accuracy for CPR and ventilation did not reach statistical significance (p CPR =0.869 and p ventilation =0.183), and none of the tested predictors were significantly associated with evaluation accuracy. No significant differences in evaluation accuracy for CPR and ventilation videos were observed between professional groups or across tested participant characteristics.

Respiratory distress is a common reason for emergency medical service (EMS) physicians to be prehospitally involved. While the availability of telemedical EMS systems increases continuously, there is a gap in research regarding respiratory emergencies in the context of prehospital telemedicine. The aim of this study is to evaluate the quality of care provided in prehospital respiratory emergencies, managed through a tele-EMS system with a specialized EMS physician. Tele-EMS physician missions from 01/01/2019 to 12/31/2021 in Aachen, Germany, were analyzed. Adult patients presenting with dyspnea, peripheral oxygen saturation < 94%, respiratory rate > 19/min, or any combination of these factors, were included (n = 2234). Data were derived from mission protocols recorded by the attending tele-EMS physicians. Significant changes ( p  < 0.001) in vital parameters towards physiological ranges were observed. For the most common diagnoses, a significant improvement in patient condition was achieved with the use of appropriate medications. In 14 cases (0.63%), an onsite-EMS physician was requested. These cases were confirmed to involve unstable patients who required intervention of an onsite-EMS physician. The tele-EMS physician effectively bridged the time until arrival of the physician. Overall, the study demonstrated that respiratory emergencies were effectively managed using the tele-EMS physician system.

The early initiation of cardiopulmonary resuscitation (CPR) measures by non-professionals before the arrival of Emergency Medical Service (EMS) is known to be crucial for improving outcomes after out-of-hospital cardiac arrest (OHCA). We assessed the impact of deploying CPR-trained volunteers via a smartphone-based alerting system on the outcome of OHCA patients. In a retrospective nonrandomized cohort study, all OHCA cases in the city of Aachen over a six-year period were analysed. We compared patient data, CPR metrics, alerting system data as well as outcome data between the intervention and control groups. From June 2017 to May 2023, 101 out of 852 resuscitations were initiated by volunteers alerted via a smartphone-based alerting system in OHCA events. We found no overall rise in the return of spontaneous circulation (ROSC) rate. An age-dependent subgroup analysis indicated an increased incidence of initially shockable rhythms and an increased ROSC rate for patients younger than 60 years in the intervention group, while implying a lower ROSC rate in patients older than 80 years after mobile responder CPR. Although this study was underpowered to yield statistically significant results, our findings suggest the need for an age-sensitive approach when evaluating the effects of first-responder systems on OHCA cases.

Although respiratory distress is one of the most common complaints of patients requiring emergency medical services (EMS), there is a lack of evidence on important aspects. Our study aims to determine the accuracy of EMS physician diagnostics in the out-of-hospital setting, identify examination findings that correlate with diagnoses, investigate hospital mortality, and identify mortality-associated predictors. This retrospective observational study examined EMS encounters between December 2015 and May 2016 in the city of Aachen, Germany, in which an EMS physician was present at the scene. Adult patients were included if the EMS physician initially detected dyspnea, low oxygen saturation, or pathological auscultation findings at the scene (n = 719). The analyses were performed by linking out-of-hospital data to hospital records and using binary logistic regressions. The overall diagnostic accuracy was 69.9% (485/694). The highest diagnostic accuracies were observed in asthma (15/15; 100%), hypertensive crisis (28/33; 84.4%), and COPD exacerbation (114/138; 82.6%), lowest accuracies were observed in pneumonia (70/142; 49.3%), pulmonary embolism (8/18; 44.4%), and urinary tract infection (14/35; 40%). The overall hospital mortality rate was 13.8% (99/719). The highest hospital mortality rates were seen in pneumonia (44/142; 31%) and urinary tract infection (7/35; 20%). Identified risk factors for hospital mortality were metabolic acidosis in the initial blood gas analysis (odds ratio (OR) 11.84), the diagnosis of pneumonia (OR 3.22) reduced vigilance (OR 2.58), low oxygen saturation (OR 2.23), and increasing age (OR 1.03 by 1 year increase). Our data highlight the diagnostic uncertainties and high mortality in out-of-hospital emergency patients presenting with respiratory distress. Pneumonia was the most common and most frequently misdiagnosed cause and showed highest hospital mortality. The identified predictors could contribute to an early detection of patients at risk.

No systematic evaluation of smartphone/mobile apps for resuscitation training and real incident support is available to date. To provide medical, usability, and additional quality criteria for the development of apps, we conducted a mixed-methods sequential evaluation combining the perspective of medical experts and end-users. The study aims to assess the quality of current mobile apps for cardiopulmonary resuscitation (CPR) training and real incident support from expert as well as end-user perspective. Two independent medical experts evaluated the medical content of CPR apps from the Google Play store and the Apple App store. The evaluation was based on pre-defined minimum medical content requirements according to current Basic Life Support (BLS) guidelines. In a second phase, non-medical end-users tested usability and appeal of the apps that had at least met the minimum requirements. Usability was assessed with the System Usability Scale (SUS); appeal was measured with the self-developed ReactionDeck toolkit. Out of 61 apps, 46 were included in the experts' evaluation. A consolidated list of 13 apps resulted for the following layperson evaluation. The interrater reliability was substantial (kappa=.61). Layperson end-users (n=14) had a high interrater reliability (intraclass correlation 1 [ICC1]=.83, P<.001, 95% CI 0.75-0.882 and ICC2=.79, P<.001, 95% CI 0.695-0.869). Their evaluation resulted in a list of 5 recommendable apps. Although several apps for resuscitation training and real incident support are available, very few are designed according to current BLS guidelines and offer an acceptable level of usability and hedonic quality for laypersons. The results of this study are intended to optimize the development of CPR mobile apps. The app ranking supports the informed selection of mobile apps for training situations and CPR campaigns as well as for real incident support.

Background A tele-emergency medical service with a remote emergency physician for severe prehospital emergencies may overcome the increasing number of emergency calls and shortage of emergency medical service providers. We analysed whether routine use of a tele-emergency medical service is non-inferior to a conventional physician-based one in the occurrence of intervention-related adverse events. Methods This open-label, randomised, controlled, parallel-group, non-inferiority trial included all routine severe emergency patients aged ≥ 18 years within the ground-based ambulance service of Aachen, Germany. Patients were randomised in a 1:1 allocation ratio to receive either tele-emergency medical service ( n  = 1764) or conventional physician-based emergency medical service ( n  = 1767). The primary outcome was the occurrence of intervention-related adverse events with suspected causality to the group assignment. The trial was registered with ClinicalTrials.gov (NCT02617875) on 30 November 2015 and is reported in accordance with the CONSORT statement for non-inferiority trials. Results Among 3531 randomised patients, 3220 were included in the primary analysis (mean age, 61.3 years; 53.8% female); 1676 were randomised to the conventional physician-based emergency medical service (control) group and 1544 to the tele-emergency medical service group. A physician was not deemed necessary in 108 of 1676 cases (6.4%) and 893 of 1544 cases (57.8%) in the control and tele-emergency medical service groups, respectively. The primary endpoint occurred only once in the tele-emergency medical service group. The Newcombe hybrid score method confirmed the non-inferiority of the tele-emergency medical service, as the non-inferiority margin of − 0.015 was not covered by the 97.5% confidence interval of − 0.0046 to 0.0025. Conclusions Among severe emergency cases, tele-emergency medical service was non-inferior to conventional physician-based emergency medical service in terms of the occurrence of adverse events.