Acute ischaemic stroke due to large-vessel occlusion requires rapid endovascular treatment (EVT). Prehospital stroke scales, though widely used, have not achieved an optimal balance of sensitivity, specificity, and overall discriminative performance, underlining the need for evaluation of machine learning (ML) approaches to improve early identification of EVT candidates. We conducted a retrospective development and internal validation study based on digital real-world data from consecutive EMS-transported patients with suspected stroke (n = 1,435, 94 EVT events [6.6%]) from the Stroke Angel initiative in a rural region in Germany (Rhön-Grabfeld), covering the period from January 2015 to June 2021. Predicted probabilities of six ML models were recalibrated using Platt scaling, and clinical relevance was evaluated using decision curve analysis (DCA). SHapley Additive exPlanations (SHAP) values were computed to quantify individual feature contributions to model predictions. Among 287 patients (24 EVT events) in the evaluation cohort, Random Forest achieved the highest AUROC (0.85 [95% CI, 0.78–0.90]), with sensitivity of 0.92 [0.74–0.99], specificity of 0.66 [0.60–0.72]. The 4I-SS (score > 2) yielded an AUROC of 0.82 [0.72–0.89], sensitivity of 0.87 [0.67–0.96], and specificity of 0.69 [0.64–0.74]. Bootstrapped intervals overlapped across all metrics, suggesting no statistically significant superiority.

Background By transmitting various types of data, telemedical care enables the provision of care where physicians and patients are physically separated. In nursing homes, telemedicine has the potential to reduce hospital admissions in nonemergency situations. In this study, telemedicine devices were implemented with the new 5G mobile communications standard in selected wards of a large nursing home in Northwest Germany. The main aim of this study is to investigate which individual and organizational factors are associated with the use of telemedicine devices and how users perceive the feasibility and implementation of such devices. Moreover, it is investigated whether the telemedical devices help to reduce the number of emergency admissions. Methods Telemedicine devices are implemented over an 18-month period using a private 5G network, and all users receive training. This study uses qualitative and quantitative methods: To assess the individual and organizational factors associated with the use of telemedicine devices, survey data from employees before and after the implementation of these devices are compared. To assess the perception of the implementation process as well as the feasibility and usability of the telemedical devices, the nursing staff, physicians, medical assistants and residents are interviewed individually. Moreover, every telemedicine consultation is evaluated with a short survey. To assess whether the number of emergency admissions decreased, data from one year before implementation and one year after implementation are compared. The data are provided by the integrated dispatch centre and emergency medical services (EMS) protocols. The interview data are analysed via structured qualitative content analysis according to Kuckartz. Survey data are analysed using multivariable regression analysis. Discussion Learnings from the implementation process will be used to inform future projects implementing telemedicine in care organizations, making the final telemedicine implementation and care concept available to more nursing homes and hospitals. Moreover, the study results can be used to provide use cases for appropriate and targeted application of telemedicine in nursing homes and to define the role of 5G technologies in these use cases. If the intervention is proven successful, the results will be used to promote 5G network rollout. Trial registrationGerman Clinical Trials Register - trial registration number: DRKS00030598.

Zusammenfassung Ziel des digitalen Notfallmanagements ist, dass alle Akteure der Rettungskette sich bei einem Notfalleinsatz elektronisch miteinander austauschen und auf alle Informationen, die für die optimale Versorgung der Patientin relevant sind, zugreifen und miteinander kommunizieren können. Für den Einsatz der Digitalisierung im Notfallmanagement existieren mittlerweile zahlreiche Konzepte mit vielversprechenden Studienergebnissen und Implementierungserfahrungen, die in einer (über)regionalen Behandlungsstrategie mit einem kontinuierlichen Verbesserungsprozess mit Nachdruck zu verstetigen sind. Unter Berücksichtigung aktueller Möglichkeiten der Digitalisierung der Rettungskette hat der Expertenrat des Zentrums für Telemedizin Bad Kissingen (ZTM) wesentliche Inhalte und Kernfunktionen des digitalen Notfallmanagements definiert.

Zusammenfassung Hintergrund und Fragestellung Steigende Anforderungen an Dokumentation und sektorenübergreifende Kommunikation führen zu vermehrtem organisatorischem Aufwand im Notarzt- und Rettungsdienst. Die Verwendung digitaler Informationssysteme im präklinischen Einsatz kann sowohl dazu beitragen, Einsatzkräfte bei diesen Aufgaben zu unterstützen als auch neue Behandlungsmöglichkeiten für Patienten eröffnen. Die Arbeit versucht, ein möglichst umfassendes Bild der derzeitigen Verbreitung und Nutzung von Informations- und Kommunikationssystemen zur Einsatzunterstützung in Deutschland zu erstellen. Material und Methoden Die Querschnittsstudie wurde als deutschlandweite, explorative Online-Befragung unter Notärzten und Rettungsdienstfachpersonal von Juli bis August 2020 durchgeführt. Die anschließende Datenanalyse erfolgte durch deskriptive Statistikmethoden. Betrachtet wurden u. a. Lösungen für die digitale Dokumentation und Krankenhausvoranmeldung, für den Versorgungsnachweis und Telenotarztdienst sowie der Digitalfunk. Ergebnisse Es wurden 821 Antwortbogen von 481 Rettungswachen aus insgesamt 382 Städten in der Auswertung berücksichtigt. Die Verfügbarkeit von 16 untersuchten Systemen variiert deutschlandweit je nach Bundesland und Anwendungsbereich. Befragte Einsatzkräfte zeigen sich gegenüber neuen Technologien und Möglichkeiten grundsätzlich offen, wenngleich die aktuelle Umsetzung als nicht zufriedenstellend bewertet wird. Herausforderungen zeigen sich v. a. hinsichtlich Verlässlichkeit, Hardware, Benutzerfreundlichkeit und Interoperabilität. Diskussion Eine weitreichende Digitalisierung der präklinischen Notfallmedizin wurde in Deutschland bislang nicht erreicht. Die ganzheitliche Betrachtung und vernetzte Implementierung aller am Einsatz beteiligten Systeme und Prozesse kann dazu beitragen, digitale Lösungen für die Präklinik zu verbessern und weiter zu verbreiten.

Introduction: Door-to-CT scan time (DCT) and door-to-needle time (DNT) are important process measures in acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis (IVT). We examined the impact of a telemedical prenotification by emergency medical service (EMS) (called the “Stroke Angel” program) on DCT and DNT and IVT rate compared to standard of care. Patients and Methods: Two prospective observational studies including AIS patients admitted via EMS from 2011 to 2013 (cohort I; n = 496) and from January 1, 2015 to May 31, 2018 (cohort II; n = 349) were conducted. After cohort I, the 4-Item Stroke Scale and a digital thrombolysis protocol were added. Multivariable logistic and linear regression analysis was performed. Results: In cohort I, DCT was lower in the intervention group (13 vs. 26 min using standard of care; p < 0.001), but no significant difference in median DNT (35 vs. 39 min; p = 0.24) was observed. In cohort II, a reduction of DCT (8 vs. 15 min; p < 0.001) and DNT (25 vs. 29 min p = 0.003) was observed in the intervention group. Compared to standard of care, the likelihood of DCT ≤10 min or DNT ≤20 min in the intervention group was 2.7 (adjusted odds ratio [aOR] 2.7; 95% CI: 2.1–3.5) and 1.8 (aOR 1.8; 95% CI: 1.1–2.9), respectively. In cohort II, IVT rate was higher (aOR 1.4; 95% CI: 1.1–1.9) in the intervention group. Conclusion: Although the positive effects of Stroke Angel in AIS provided a rationale for implementation in routine care, larger studies of practice implementation will be needed. Using Stroke Angel in the prehospital management of AIS impacts on important process measures of IVT delivery.

ABKÜRZUNGEN 4I-SS 4-Item-Stroke Scale ACI A. carotis interna DCT Door-to-CT Time DGT Door-to-Groin Time DNT Door-to-Needle Time FAST-Test Face-Arm-Speech-Time-Test GRT Groin-to-Reperfusion Time M1/M2 Segment 1/2 der A. cerebri media NIHSS National Institute of Health Stroke Scale RFID Radio Frequency Identification WLAN Wireless Local Area Network Die Herausforderung für den Rettungsdienst besteht darin, die Leitsymptome des Schlaganfalls frühzeitig zu erkennen, korrekt zu dokumentieren, die nächstgelegene geeignete Klinik mit einer Stroke Unit auszuwählen und über den Schweregrad des Schlaganfalls bestmöglich vorab zu informieren.

Emergency departments need to continuously calculate quality indicators in order to perform structural improvements, improvements in the daily routine, and ad-hoc improvements in everyday life. However, many different actors across multiple disciplines collaborate to provide emergency care. Hence, patient-related data is stored in several information systems, which in turn makes the calculation of quality indicators more difficult. To address this issue, we aim to link and use routinely collected data of the different actors within the emergency care continuum. In order to assess the feasibility of linking and using routinely collected data for quality indicators and whether this approach adds value to the assessment of emergency care quality, we conducted a single case study in a German academic teaching hospital. We analyzed the available data of the existing information systems in the emergency continuum and linked and pre-processed the data. Based on this, we then calculated four quality indicators (Left Without Been Seen, Unplanned Reattendance, Diagnostic Efficiency, and Overload Closure). Lessons learned from the calculation and results of the discussions with staff members that had multiple years of work experience in the emergency department provide a better understanding of the quality of the emergency department, the related challenges during the calculation, and the added value of linking routinely collected data.

Die Versorgung von Schwerverletzten ist eine besondere Herausforderung für die Zusammenarbeit von Rettungsdienst und Zentraler Notaufnahme (ZNA). Für die ZNA ist eine frühzeitige und aussagekräftige Information zum Zustand des Patienten noch vor Eintreffen in der Notaufnahme für die Vorbereitung notwendiger Ressourcen von großer Bedeutung.

BACKGROUND:Trauma is a global burden. Emergency medical services (EMS) provide care for individuals who have serious injuries or suffered a major trauma.OBJECTIVE:This paper provides a comprehensive overview of telemedicine applications in prehospital trauma care.METHODS:We conducted a systematic review according to PRISMA guidelines. We identified articles by electronic database search (PubMed, EMBASE, the Cochrane Library, CINAHL, SpringerLink, LIVIVO, DARE, IEEE Xplore, Google Scholar and ScienceDirect) using keywords related to prehospital settings, ambulance, telemedicine and trauma. Search terms and inclusion criteria were specified a priori by the PICOS template and revised throughout a configurative approach iteratively, to outline the complexity and variety of different telemedical concepts.RESULTS:A final sample of 15 records was systematically selected. Most interventions were piloted and/or evaluated in Germany for trauma victims in prehospital settings. Six studies were simulated scenarios. Telemedical assistance (TMA) via real-time telemetry systems (RTS), enabling video and audio conferencing between EMS by tele-emergency physicians (TEP) were associated with a higher treatment quality and a shorter time-to-treatment in invasive procedures. By initiating in-hospital preparations based on telemedical prehospital notification (TPN), loss of information during the clinical handover was reduced and in-hospital protocols were activated with high accuracy. Remotely guided ultrasound (Tele-Ultrasound) by TEP showed an overall high diagnostic accuracy in simulations. Technical solutions were reliable, seemed practical and auspicious.CONCLUSION:The review indicates that TMA and TPN are accompanying telemedical concepts in out-of-hospital trauma care. Well-designed populated studies are needed to fully assess the effect of telemedicine in acute trauma care. Therefore, evidence regarding the effectiveness of telemedicine in prehospital setting for trauma patients is still limited.

Jeder kennt die Situation: Am Ende einer Schicht passiert der Einsatztag vor dem geistigen Auge Revue. Prägnant sind dabei auch die unbeliebten Aufgaben: langwieriges Telefonieren mit Krankenhäusern, Warten in der Notaufnahme oder das lästige Ausfüllen des Rettungsdienstprotokolls. Doch das alles könnte bald der Vergangenheit angehören.