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Paula Hofstetter,1,2 Hanna Schröder,1,3 Stefan K Beckers,1,3,4 Christina Borgs,1 Rolf Rossaint,1 Marc Felzen1,3,4 1Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany; 2Department of Anesthesiology, Rhein-Maas Klinikum, Würselen, Germany; 3Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany; 4Medical Direction of Aachen Fire Department, Aachen, GermanyCorrespondence: Marc Felzen, Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany, Tel +49 241 8088179, Fax +49 241 82406, Email mfelzen@ukaachen.deBackground: The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device.Methods: A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter.Results: Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard.Conclusion: It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.Keywords: immobilization, trauma, emergency medicine, Canadian C-spine rule, NEXUS-criteria, tele-emergency medicine

Background: External chest compressions (ECC) are essential components of resuscitation and are usually performed without any adjuncts in professional healthcare. Even for healthcare professionals during in-hospital and out-of-hospital resuscitation poor performance in ECC has been reported in recent years. Although several stand-alone devices have been developed none has been implemented as a standard in patient care. The aim of this study was to examine if the use of a mechanical device providing visual feedback and audible assistance during ECC improves performance of healthcare professionals following minimal and simplified instructions.Methods: In a prospective, randomized cross-over study 81 healthcare professionals performed ECC for 3 min (in the assumed setting of a secured airway) twice on a manikin (Skillreporter ResusciAnne®, with PC-Skillreporting System Version 1.3.0, Laerdal, Stavanger, Norway) in a mock cardiac arrest scenario. Group 1 (n=40) performed ECC with the device first followed by classic ECC and group 2 (n=41) in the opposite order. Minimal instructions were standardized and provided by video instruction (1 min 38 s). Endpoints were achievement of a mean compression rate between 90 and 110/min and a mean compression depth of 40-50 mm. In addition participants had to answer questionnaires about demographic data, professional experience and recent recommendations for ECC as well as their impression of the device concerning the ease of use and their personal level of confidence. Data were analyzed for group-related and inter-group differences using SAS (Version 9.1.3, SAS Institute, Cary, NC).Results: A total of 81 healthcare professionals regularly involved in resuscitation attempts in pre-hospital or in-hospital settings took part in the study with no differences between the groups: females 35.8% (n=52), emergency medical technicians 32.1% (n=26), anesthesia nurses 32.1% (n=26), physicians (anesthesiology) 45% (n=29). In group 1 33 out of 40 (82.5%; 99.7±4.82/min; 95% confidence interval 95% CI: 98.1-101.2/min) reached the correct range for compression rate and 29/40 (72.5%; 44.0±4.95 mm; 95% CI: 42.4-45.6 mm) the correct compression depth using the assisting device. Afterwards they conducted classic ECC without the device and deteriorated significantly: correct compression rate was achieved by 12/40 (30%, p≤0.0001; 110.6±11.0/min (95% CI: 107.1-114.1/min), while 25/40 (62.5%; 44.5±5.63 mm; 95% CI: 42.6-46.3 mm) met the correct compression depth. Group 2 performed poorer in ECC without assistance and 5/41 (12.2%; 104.5±21.35/min; 95% CI: 97.8-111.3/min) reached the correct rate whereas 21/41 (51.2%; 39.6±7.61 mm; 95% CI: 37.2-42.0 mm) compressed to the appropriate depth. Using the device there was a significant improvement in the second evaluation with 34/41 (82.9%, p≤0.0001; 101.7±4.68/min; 95% CI: 100.2-103.2/min) reaching the correct rate and 36/41 (87.8%, p≤0.0001; 43.9±4.16 mm; 95% CI: 42.6-45.2 mm) the correct depth.Conclusions: The tested device is easy to use after instruction of less than 3 min and improves ECC performance of healthcare professionals in simulated cardiac arrest with respect to compression depth as well as compression rate. [ABSTRACT FROM AUTHOR]

Background: The emergency medical service (EMS) should work according to criteria of evidence-based medicine. In Germany the EMS of each state is under the control of at least one medical supervisor known as emergency medical directors (EMD) and most states have several different EMDs responsible for one or more provinces of the state. The German Medical Association advises these supervisors to specify the pharmacological resources in store for use in physician powered EMSs. This study examines the pharmacological resources in EMSs which is provided by the EMDs in Germany. Furthermore, a comparison of the inventory analysis of stored drugs was carried out with the requirements according to guidelines for selected tracer diagnoses.Method: In the period of May 2008 to January 2009 a total of 148 EMDs were contacted and asked to supply drug storage lists for emergency physician-staffed rescue vehicles in their respective jurisdiction. The addresses of all EMDs who could be identified by the federal office of the National Association of Emergency Medical Director, Germany were used over the period. The evaluation was conducted anonymously. The tracer diagnoses "cardiopulmonary resuscitation", "acute coronary syndrome", "status generalized tonic-clonic seizure," "severe asthma attack", "acute exacerbation of chronic obstructive pulmonary disease", "supraventricular tachycardia", "severe brain trauma" and "acute heart failure with signs of hypoperfusion" were selected. Current and established guidelines have been identified with the homepage of the Scientific Medical Societies in Germany and supported by the leading European and International guidelines.Results: The corresponding lists were returned by 95 different emergency service areas (response rate 64.2%). With a total of 39 groups of substances 142 different drugs could be identified, an average of 54±9.6 and median 55 (range 31-77). Listed are agents giving the provision in percent, for which the comparison with guidelines for tracer diagnoses could show deficits: sodium bicarbonate 75.8%, calcium 50.5%, magnesium 45.3%, noradrenaline 65.3%, adenosine 58.9%, dobutamine 57.9%, lorazepam iv 13.7%, salbutamol 41.1%, ipratropium bromide 13.7% (the last two as liquid preparations for inhalation). With a frequency of about 30-80%, depending on the respective tracer diagnosis, no medical emergency treatment according to the highest level of evidence is possible.Conclusion: Due to recent treatment recommendations provision with sodium bicarbonate, calcium, magnesium, noradrenaline, adenosine, lorazepam iv, dobutamine and as well with ipratropium bromide and salbutamol (both as liquid preparations for inhalation) should be improved. For the future, a federal uniform minimum standard due to evidence-based principles is desirable. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to examine documentation quality in physician staffed emergency medical services (EMS). This study compared simulated on-site care with the associated patient records written by EMS physicians.Methods: For this study two standardized simulated case scenarios, ST segment elevation myocardial infarction (STEMI) and major trauma with traumatic brain injury were designed by an expert committee. Overall 29 EMS teams each consisting of 1 EMS physician and 2 paramedics ran through the scenarios on high fidelity patient simulators and each scenario was videotaped. The scenarios were stopped after 12 min for STEMI and after 14 min for major trauma independent of the actions carried out and each EMS physician then had 10 min to document this initial phase on standardized protocol sheets. The videotaped scenarios were analyzed by two independent investigators. Documentation of predefined contents and all drug dosages were checked against the simulated on-site care. The data were evaluated and classified as correct, incorrect or missing documentation although action performed.Results: Written consent for data analysis was provided by 28 teams. Overall 20 parameters and actions in the STEMI scenario and 16 in the major trauma scenario as well as all drug dosages were evaluated. For the scenario STEMI 469 actions were analyzed of which 271 (58%) were correct, 94 (20%) incorrect and 104 (22%) had missing documentation. A total of 140 medications were administered of which 31 (22%) were documented incorrectly and 14 (10%) were not documented. For major trauma 401 actions were analyzed of which 244 (61%) were correct, 101 (25%) incorrect and 56 (14%) had missing documentation. In this scenario the teams administered 138 medications of which 31 (22%) were documented incorrectly and 16 (12%) were not documented. Infused amounts of crystalloids and colloids were mostly documented correctly in this case (35 correct /6 incorrect/8 not documented). Documentation of several clinical parameters was carried out predominantly correctly, e.g. initial blood pressure (STEMI: 25/2/1, major trauma: 21/4/2) and initial ECG rhythm (STEMI: 27/0/1, major trauma: 26/0/1). Documentation of other clinically relevant parameters was often performed incorrectly: 12-lead ECG in STEMI (5/9/12) and capnometry in major trauma (9/4/7). No team used a pain scale to assess the level of pain in the STEMI scenario but 12 EMS physicians documented an accordant value (numerical rating scale) on the patient records. Furthermore some parameters could be identified where documentation was mostly missing although they were measured, e.g. onset of symptoms in STEMI (5/4/15) and reduced level of consciousness and bradypnea in major trauma (9/2/17).Conclusion: Patient safety can be reduced if relevant preclinical data are not transmitted correctly to the admitting hospital. Therefore there is a need to improve documentation quality in EMS. Electronic documentation, training of EMS staff and quality management programs might offer solutions. Because of the small sample size further studies are needed to evaluate the validity of these results. [ABSTRACT FROM AUTHOR]

Background: In order to provide early achievement of practical experience during medical education, the medical faculty of the university Aachen has developed a new medical school curriculum which was offered in 2003 for the first time. In this curriculum anaesthesiology became a compulsory subject with practical training both in the operation theatre and in emergency medicine. Accordingly, a practical course in the field of intensive care medicine has also been designed with respect to the planned schedule and personnel resources. This course was evaluated by both students and teaching staff in a written, anonymous form as a quality control.Methods: A dedicated course was developed for medical students of the 8th and 9th semesters. In this course comprised of 6 students and lasting 1 week, practical training is provided by intensive care physicians and accompanied by theoretical lessons focusing on the definition, diagnosis, therapy and prophylaxis of sepsis, essentials of mechanical ventilation and patient presentation at the bedside during daily rounds. On the last day of training students were required to present patients by themselves thereby recapitulating the acquired knowledge. In the summer semester 2007 this intensive care training course was offered for the first time. All participating 83 students and 23 physicians involved in teaching evaluated the course with marks from 1 to 6 according to the standard German school grading system using an online questionnaire.Results: Students rated the course with 1.6+/-0.7 (mean +/- SD) for comprehensibility, with 1.6+/-0.7 for structural design, and with 1.7+/-0.7 for agreement between teachers. They graded their personal learning success with 1.7+/-0.7. With a cumulative mark of 1.7+/-0.6, the course was ranked as 1 of the top 3 courses of the medical faculty from the very beginning. The majority of the teaching staff (80%) appreciated the focus on few selected teaching subjects. However, comprehensibility, structural design, agreement between teachers and personal learning success were graded one mark worse than by the students.Conclusions: According to the results, efficiency and acceptance of intensive care training courses were high. Major criteria for the high grading were a limited number of participants, the focus on few subjects, and a clear structural design. However, according to several personal notes from the students, simulation-based sessions and written teaching material might further improve success of this course. [ABSTRACT FROM AUTHOR]

Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances for cardiac arrest must be considered resulted in a separate chapter. This two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of electrolyte disorders, hyperthermia and hypothermia, cardiac arrest in pregnancy, trauma, electrical emergencies and cardiac surgery. Part 1 has already dealt with life-threatening drowning, asthma, anaphylaxis and poisoning. [ABSTRACT FROM AUTHOR]

Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances sometimes must be considered in patient treatment resulted in a separate chapter. This first part of a two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of life-threatening drowning, asthma, anaphylaxis, and poisoning. The second part will deal with electrolyte disorders, hypothermia, electrical emergencies, trauma, cardiac arrest during pregnancy, and cardiac surgery. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Data availability: The datasets analyzed in the current study are not publicly available because they are municipal property and cannot be published online under open-access agreements. However, these datasets are available upon reasonable request and with permission from municipal authorities. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: In Germany, the number of emergency missions has been rising for several years. At the same time, it can be observed that the amount of missions involving emergency physicians is decreasing, while the number of outpatient treatments without transport is increasing. To cope with this situation, different alternative care concepts have been developed as complementary resources throughout Germany. This study comprehensively compares these concepts, and it aims to highlight best-practice examples and stimulate a joint learning process., Methods: As part of an online survey project leaders of various concepts were asked to take part in a standardized online survey. The survey comprised a total of 28 questions relating to various areas such as qualifications and training or resource equipment. The information was supplemented by documents, which were additionally submitted by the respondents., Results: A total of seven concepts were examined. They all have in common that they are alerted by the dispatch centers to care mainly for low-code cases. Furthermore, the resources are staffed by trained paramedics, and patient transport is not possible. All resources are able to contact other medical facilities. Differences can be seen in the areas of funding, training, equipment, availability, and further areas of responsibility., Discussion: The development of a large number of different care concepts in Germany has taken place in parallel with the development in other European countries, where different approaches have also been established for low-priority requests for assistance. In order to direct low-priority requests for assistance to a needs-based care unit in Germany as well, rescue dispatch centers should have a broader repertoire of care at their disposal. Implications for research arising from this lie in particular in evaluating the various concepts adequately, especially with regard to the quality of care, and thus ensuring needs-based and targeted care., Conclusion: Widespread introduction of alternative care concepts might help relieve the burden on emergency medical care. This requires more research and evaluation as well as optimized data quality and standardization. In addition, it is desirable to enhance cooperation with the medical on-call service., (Copyright © 2024. Published by Elsevier GmbH.)

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., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Beierle et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

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., (© 2024. The Author(s).)

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., (© 2023. The Author(s).)

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., (© 2023. The Author(s).)

Background: Systems thinking can be used as a participatory data collection and analysis tool to understand complex implementation contexts and their dynamics with interventions, and it can support the selection of tailored and effective implementation actions. A few previous studies have applied systems thinking methods, mainly causal loop diagrams, to prioritize interventions and to illustrate the respective implementation context. The present study aimed to explore how systems thinking methods can help decision-makers (1) understand locally specific causes and effects of a key issue and how they are interlinked, (2) identify the most relevant interventions and best fit in the system, and (3) prioritize potential interventions and contextually analyse the system and potential interventions., Methods: A case study approach was adopted in a regional emergency medical services (EMS) system in Germany. We applied systems thinking methods following three steps: (1) a causal loop diagram (CLD) with causes and effects (variables) of the key issue "rising EMS demand" was developed together with local decision-makers; (2) targeted interventions addressing the key issue were determined, and impacts and delays were used to identify best intervention variables to determine the system's best fit for implementation; (3) based on steps 1 and 2, interventions were prioritized and, based on a pathway analysis related to a sample intervention, contextually analysed., Results: Thirty-seven variables were identified in the CLD. All of them, except for the key issue, relate to one of five interlinked subsystems. Five variables were identified as best fit for implementing three potential interventions. Based on predicted implementation difficulty and effect, as well as delays and best intervention variables, interventions were prioritized. The pathway analysis on the example of implementing a standardized structured triage tool highlighted certain contextual factors (e.g. relevant stakeholders, organizations), delays and related feedback loops (e.g. staff resource finiteness) that help decision-makers to tailor the implementation., Conclusions: Systems thinking methods can be used by local decision-makers to understand their local implementation context and assess its influence and dynamic connections to the implementation of a particular intervention, allowing them to develop tailored implementation and monitoring strategies., (© 2023. The Author(s).)

Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘DF is co-founder and operations manager of the Heartrunner Citizen Responder System, Sweden and member of the tech&ops committee of EENA (European Emergency Number Association). CM is Guest Editor special issue “Impact of First Responders in Resuscitation” in Resuscitation Plus. MPM is chair of Region of Lifesavers, shareholder of SmartResQ ApS, and received speaker honoraria from Stryker. TS is the Social Media Editor of Resuscitation and Resuscitation Plus journals. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper’.

In the Emergency Medical Service Acts of the Federal States, the statements in these Acts have so far essentially been limited to the implementation of measures to maintain the health of emergency patients and to transport them to a suitable hospital. Preventive fire protection, on the other hand, is regulated in the Fire Brigade Acts or by statutory ordinances. Increasing numbers of emergency service missions and a lack of facilities for alternative care justify the need for a preventive emergency service. This includes all measures that take place before an event occurs in order to prevent emergencies from occurring. As a result, the risk of an emergency event leading to the emergency call 112 should be reduced or delayed. The preventive rescue service should also help to improve the outcome of medical care for patients. Furthermore, it should be made possible to provide those seeking help with a suitable form of care at an early stage., (© 2023. The Author(s).)

A noninvasive tool for cardiovascular risk stratification has not yet been established in the clinical routine analysis. Previous studies suggest a prolonged T peak -T end interval (the interval from the peak to the end of the T-wave) to be predictive of death. This meta-analysis was designed to systematically evaluate the association of the T peak -T end interval with mortality outcomes. Medline (via PubMed), Embase and the Cochrane Library were searched from 1 January 2008 to 21 July 2020 for articles reporting the ascertainment of the T peak -T end interval and observation of all-cause-mortality. The search yielded 1920 citations, of which 133 full-texts were retrieved and 29 observational studies involving 23,114 patients met the final criteria. All-cause deaths had longer T peak -T end intervals compared to survivors by a standardized mean difference of 0.41 (95% CI 0.23-0.58) and patients with a long T peak -T end interval had a higher risk of all-cause death compared to patients with a short T peak -T end interval by an overall odds ratio of 2.33 (95% CI 1.57-3.45). Heart rate correction, electrocardiographic (ECG) measurement methods and the selection of ECG leads were major sources of heterogeneity. Subgroup analyses revealed that heart rate correction did not affect the association of the T peak -T end interval with mortality outcomes, whereas this finding was not evident in all measurement methods. The T peak -T end interval was found to be significantly associated with all-cause mortality. Further studies are warranted to confirm the prognostic value of the T peak -T end interval.

Background: Each year there are 7.3 million emergencies for the German rescue service, trend rising and around 59% of the emergency patients are treated by paramedics only; however, most of the studies focus on physicians, while their practical skills at the scene are rarely necessary. Accordingly, the responsibility for the patient lies with the paramedics most of the time. Their duty is to execute life-saving measures, stabilize the patient for the transport and the regular documentation of the operation. Retrospectively, the emergencies can only be analyzed based on the emergency protocols, which are mostly paper-based and handwritten. That causes an increased effort in the evaluation, which makes studies for the whole country hardly feasible. As of now there are only few data on quality of healthcare and documentation by the paramedics. Both were analyzed in this survey based on the emergency protocols., Method: A retrospective analysis of emergency protocols from June to July 2018 took place in Aachen, a major German city. A specific feature of Aachen is a 24‑h available emergency physician via telemedicine. The quality of documentation and healthcare was analyzed by including standard operating procedures. Primary endpoints were the frequency of documentation, the achievement of complete documentation, the correct indications for a physician, the development of critical vital signs and the average on-scene time of the ambulance., Results: Overall, 1935 protocols were analyzed. A complete documentation was achieved in 1323 (68.4%) suspected diagnoses, 456 (23.6%) anamneses, 350 (18.1%) initial and 52 (2.7%) vital signs at handover. Based on the documentation, there were 531 cases (27%) of patients treated by paramedics only, even though a physician would have been indicated. Out of those patients 410 critical initial vital signs were documented of which 69 (16.8%) improved, while there was no documentation of vital signs at handover in 217 (52.9%). Also, there was a significantly prolonged on-scene time for patients with belated indications for an emergency physician with 15:02 min in comparison to 13:05 min for patients without indications., Conclusion: Deficient documentation was found in multiple cases and several important vital signs for a complete differential diagnosis were missing. Furthermore, a quarter of all patients might have benefited from an emergency physician as they were taken to hospital with no or insufficient treatment, despite standard operating procedures. From a forensic point of view there is an alarmingly incomplete documentation of vital signs at handover. The on-scene time in general was within the predetermined time frame, but can still be reduced in different scenarios. Overall, we recommend strict adherence to the standard operating procedures and algorithms, to remove unnecessary documentation and implement a structured quality assurance. Moreover, the quality of treatment might benefit from the rising number of more specialized paramedics and an increasing use of telemedicine., (© 2022. The Author(s).)

Background: 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., Objectives: 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., Methods: 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., Results: 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)., Conclusions: 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., Competing Interests: The authors have declared that no competing interests exist.

Background: In the Euregio-Meuse-Rhine (EMR), cross-border collaboration is essential for resource-saving and needs-based patient care within the emergency medical service (EMS) systems and interhospital transport (IHT). However, at the onset of the novel coronavirus SARS-COV-2 (COVID-19) pandemic, differing national measures highlighted the fragmentation within the European Union (EU) in its various approaches to combating the pandemic. To assess the consequences of the pandemic in the EMR border area, the aim of this study was to analyze the effects and "lessons learned" regarding cross-border collaboration in EMS and IHT., Method: A qualitative study with 22 semi-structured interviews was carried out. Experts from across the EMR area, including the City of Aachen, the City region of Aachen, the District of Heinsberg (Germany), South Limburg (The Netherlands), and the Province of Limburg, as well as Liège (Belgium), took part. The interviews were coded and analyzed according to changes in cross-border collaboration before and during the pandemic, as well as lessons learned and recommendations., Results: Each EU member country within the EMR area, addressed the pandemic individually with national measures. Cross-border collaboration between regional actors was hardly or not at all addressed at the national level during political decision- or policymaking. Previous direct communication at the personal level was replaced by national procedures, which made regular cross-border collaboration significantly more difficult. The cross-border transfer regulations of patients with COVID-19 proved to be complex and led, among other things, to patients being transported to hospitals far outside the border region. Collaboration continues to be seen as valuable and Euregional emergency services including hospitals work well together, albeit to different degrees. The information and data exchange should, however, be more transparent to use resources more efficiently., Conclusion: Effective Euregional collaboration of emergency services is imperative for public safety in a multi-border region with strong economic, cultural, and social cross-border links. Our findings indicate that existing (pre-pandemic) structures which included regular meetings of senior managerial staff in the region and a number of thematic working groups were helpful to deal with and to compensate for the disruptions during the crisis. Regional cross-border agreements that are currently based on mutual but more or less informal arrangements need to be formalized and better promoted and recognized also at the national and EU level to increase resilience. The continuous determination of synergies and good and best practices are further approaches to support cross-border collaboration especially in preparation for future crises., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sommer, Rehbock, Vos, Borgs, Chevalier, Doreleijers, Gontariuk, Hennau, Pilot, Schröder, Van der Auwermeulen, Ghuysen, Beckers and Krafft.)

Background: Emergency training is designed to improve medical care teams' knowledge, practical skills, and treatment procedures in patient care to increase patient safety. This requires effective training, but the multifactorial effects of training are difficult to measure., Methods: We assessed the impact of emergency team training on treatment procedures and quality, processes, technical skills, and nontechnical skills in simulated trauma emergencies in a longitudinal analysis, using videos that were recorded before (t0), immediately after (t1), and 1 year after the training (t2). The training was evaluated with the validated PERFECT checklist, which includes 7 scales: primary assessment, secondary assessment, procedures, technical skills, trauma communication, nontechnical skills, and a global performance scale.The primary end point was the change from before a training intervention (t0) to 1 year after training (t2), measured by a metric point score. The second end point was the impact of the intervention from before training to after and from immediately after training to 1 year later., Results: A total of 146 trainings were evaluated. In simulated traumatological emergencies, training participants showed significantly better treatment capacity after 1 year (t0: 28.8 ± 5.6 points versus t2: 59.6 ± 6.6 points, P < 0.001), with greater improvement from t0 to t1 (28.8 ± 5.6 points versus 65.1 ± 7.9 points, P < 0.001). The most significant change from t0 to t2 was seen in the primary assessment, with a mean change of 11.1 ± 5.1, followed by the scale of the procedure (6.1 ± 3.0) and nontechnical skills (6.0 ± 3.0)., Conclusions: Team trainings with intensive scenario training and short theoretical inputs lead to a significant improvement in simulated care of severely injured patients, especially in identifying and intervening in life-threatening symptoms, processes, and nontechnical skills, even 1 year after the course. Positive, longitudinally positive effects were also in communication and subjective safety of prehospital health care personnel., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Interhospital transports of critically ill patients are high-risk medical interventions. Well-established parameters to quantify the quality of transports are currently lacking. We aimed to develop and cross-validate a score for interhospital transports., Setting: An expert panel developed a score for interhospital transport by a Mobile Intensive Care Unit (MICU), the QUality of Interhospital Transportation in the Euregion Meuse-Rhine (QUIT-EMR) score. The QUIT-EMR score is an overall sum score that includes component scores of monitoring and intervention variables of the neurological (proxy for airway patency), respiratory and circulatory organ systems, ranging from -12 to +12. A score of 0 or higher defines an adequate transport. The QUIT-EMR score was tested to help to quantify the quality of transport., Participants: One hundred adult patients were randomly included and the transport charts were independently reviewed and classified as adequate or inadequate by four transport experts (ie, anaesthetists/intensivists)., Outcome Measures: Subsequently, the level of agreement between the QUIT-EMR score and expert classification was calculated using Gwet's AC 1 ., Results: From April 2012 to May 2014, a total of 100 MICU transports were studied. The median (IQR) QUIT-EMR score was 1 (0-2). Experts classified six transports as inadequate. The percentage agreement between the QUIT-EMR score and experts' classification for adequate/inadequate transport ranged from 84% to 92% (Gwet's AC 1 0.81-0.91). The interobserver agreement between experts was 87% to 94% (Gwet's AC 1 0.89-0.98)., Conclusion: The QUIT-EMR score is a novel validated tool to score MICU transportation adequacy in future studies contributing to quality control and improvement., Trial Registration Number: NTR 4937., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© 2021. The Author(s).)

Background: Teaching of resuscitation measures is not mandatory in all schools in Germany. It is currently limited to individual, partly mandatory projects despite a low bystander resuscitation rate. For this reason, the Ministry for Schools and Education of North Rhine-Westphalia initiated the project "Bystander resuscitation at schools in NRW" in March 2017., Objective: The aim of this work was to evaluate this project., Material and Methods: All secondary schools in North Rhine-Westphalia were invited to participate in the project. Medical partners from each administrative district took part, who carried out resuscitation training with existing concepts for teacher or student training. After a 3-year period, the evaluation was carried out using standardized questionnaires for school headmasters, teachers and students., Results: In total, more than 40,000 pupils from 249 schools in NRW could be trained in resuscitation within the project with 6 different concepts. Of the students 85% answered the questions regarding resuscitation correctly and overall felt safe in resuscitation measures. The one-off investment requirement for all schools is roughly 4-6.5 million € and around 340,000 € in each budget year., Conclusion: A legal constitution and funding are necessary for a nationwide introduction of resuscitation in schools. All established concepts are effective, therefore each school can use them exactly according to their needs, optimally in a stepped form. Training for teachers should focus on resuscitation.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application., (Copyright © 2020. Published by Elsevier B.V.)

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.

Background: The number of interhospital transfers is constantly increasing because of specialization of medical facilities, capacity balancing between intensive care units as well as earlier rehabilitation procedures. This leads to an increase in requests for emergency physicians to accompany patient transfers. This study investigated whether clarification of interhospital transport by an emergency physician at the dispatch center can optimize the use of emergency services resources., Method: All transport clarifications performed by a tele-emergency physician between 1 January 2018 and 31 December 2019 were retrospectively analyzed as well as the transport request forms. Furthermore, all data on the number and alarmed rescue resources for interhospital transfers in the city of Aachen from 2013 onwards were exported from the dispatch center databank and included in the evaluation., Results: In total 2333 requests for interhospital patient transfers from 2018 and 2019 were analyzed as well as 10,923 transports recorded from 2013 to 2019. The number of patient transfers accompanied by an emergency physician from 2013 to 2019 was significantly reduced from 786 (68.2%) to 495 (30.5%, p > 0.001). The correct resources of rescue vehicles and staff was requested in 1816 cases (77.8%). The urgency of emergency patient transfers was correctly evaluated in 567 (89.2%) cases. In total 526 assignments were carried out without an emergency physician and 315 of these patients were accompanied by a tele-emergency physician during transfer., Conclusion: The immediate clarification of interhospital transport requests by an emergency physician at the dispatch center leads to a significant reduction in unnecessary medical accompaniment of patient transfers. The choice of an appropriate transfer vehicle and staff should not be left to the requesting hospital physician alone.

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.

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., (©Marc Felzen, Stefan Kurt Beckers, Felix Kork, Frederik Hirsch, Sebastian Bergrath, Anja Sommer, Jörg Christian Brokmann, Michael Czaplik, Rolf Rossaint. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.10.2019.)