Paramedic remote support

National Guideline Centre (UK)

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Chapter 4Paramedic remote support

4. Remote access to clinical advice by ambulance staff

4.1. Introduction

Paramedics and other ambulance clinicians are well trained but expected to manage a broad range of conditions in the out-of-hospital environment. In the UK, paramedics operate as autonomous practitioners, whereas in other countries on-line medical support and advice is an established component of emergency medical systems. Mobile communication technologies have now advanced to a stage where real-time access to clinical advice, remotely from the scene of an incident, is now a possibility for UK ambulance services.

The remote provision of senior clinical advice to paramedics and other ambulance clinicians may be of value in providing authorisation for clinical interventions beyond the existing scope of practice or in assisting with clinical decision making. Examples of this could include remote interpretation of an electrocardiograph to facilitate direct access to a specialist centre, or the provision of support with decisions relating to whether a patient requires immediate transfer to an Emergency Department or could undergo alternative management in the community.

Given the uncertainty regarding this issue in UK ambulance services, the guideline committee sought to determine if immediate access to senior decision makers by ambulance staff could improve outcomes and utilisation of NHS resources.

4.2. Review question: Does the provision of immediate access by ambulance staff to clinical advice, using remote decision support reduce NHS resource usage and improve outcomes?

For full details see review protocol in Appendix A.

4.3. Clinical evidence

No relevant clinical evidence identified.

4.4. Economic evidence

Published literature

No relevant economic evaluations were included. One economic evaluation was identified but excluded due to limited applicability.²⁵ This is listed in Appendix H, with reasons for exclusion given.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

4.5. Evidence statements

Clinical

No relevant clinical evidence was identified.

Economic

No relevant economic evaluations were identified.

4.6. Recommendations and link to evidence

Recommendations	-
Research recommendations	RR2. Are paramedic remote decision-support technologies clinically and cost effective?
Relative values of different outcomes	The number of patients seeking further contacts after initial assessment by paramedic (GP, 999, ED or 111) or re-contact rates within 72 hours, quality of life, mortality and conveyance (carriage) rates were considered by the committee to be critical outcomes. Total avoidable adverse events as reported by the study, patient and/or satisfaction, number of hospital admissions and staff satisfaction were considered important outcomes.
Trade-off between benefits and harms	The committee chose to formulate a research recommendation as no direct evidence was identified which answered the question. Evidence was identified in various settings which were not thought sufficiently representative of the general population of undifferentiated acute medical emergencies, in contrast to well-characterised disease pathways (for example, ST-elevation myocardial infarction, trauma or hyper-acute stroke). In addition, no evidence was identified which was directly relevant to the UK clinical context. Advanced emergency care systems elsewhere may use doctors or employ a variety of sophisticated transport systems. For example, France’s Service Aeromedical d’Urgence (SAMU) has both doctor-based and paramedic-based (firemen) systems working in parallel. A German study of a community-based urgent response system for stroke included a mobile CT scanner in the ambulance. The committee noted that remote decision support could be beneficial whereby decisions about management can be made on site and may mean treatment could be started earlier or transport of some patients to hospital could be avoided. This might be particularly valuable in rural locations. However, the lack of evidence meant that the committee decided to make a recommendation for further research.
Trade-off between net effects and costs	No economic evaluations were included. The committee discussed the cost implications of the provision of a formal remote advice service on a national level, which would require the availability of 24-hour support from a senior healthcare professional (for example, a GP, advanced nurse practitioner or advanced paramedic). The committee considered that this could have high cost implications that would not be justifiable, given the lack of directly applicable evidence to show clinical benefit. It is likely to be more cost-effective in rural locations where the time until life-saving treatment could be considerably reduced by pre-hospital treatment. Alternatively, less severely ill patients might avoid a long journey to hospital.
Quality of evidence	No evidence was found which matched the protocol and was relevant to the UK context.
Other considerations	There is currently a variable provision of remote clinical support for paramedics in the UK. Further research is required to assess the clinical and cost effectiveness of providing remote support. The committee noted that if access to remote support modalities was already being provided, this should not be discontinued or discouraged, but rather that the introduction of such services should be accompanied by systematic evaluation as an explicit part of the policy initiative. Practice varies across the country in how paramedics access remote clinical support and the absence of research evidence prevents a recommendation on how such support should be configured. This might include how remote support systems would facilitate ‘see and treat’ decisions and potentially reduce conveyance rates, and the mechanism by which support was accessed, for example, telephone access to a general practitioner to support decision making or access to diagnostic technologies. Given the variation in service provision, the evaluation of a new or an enhanced remote support service would need to characterise how the new service differed from the current comparator service, and should employ a research design which allowed the separation of potential intervention effects from secular trends. From a legal perspective it would be important to determine where liability resides for clinical decision-making (that is, with the remote “supporter” or the “on-site” paramedic). The committee noted that electronic communications may be less reliable in rural areas and these populations could be disadvantaged (for example, poor mobile phone network coverage). However, remote support may be valuable in scenarios where the nearest hospital is some distance away. There are potential cultural barriers which should be considered when assessing this technology.

References

1.: Abrashkin KA, Washko J, Zhang J, Poku A, Kim H, Smith KL. Providing acute care at home: community paramedics enhance an advanced illness management program - preliminary data. Journal of the American Geriatrics Society. 2016; 64(12):2572–2576 [PubMed: 27575363]
2.: Adeyinka M. The teleambulance. Journal of Telemedicine and Telecare. 1996; 2:(Suppl 1):76–79 [PubMed: 9375100]
3.: Amarenco P, Nadjar M. Telemedicine for improving emergent management of acute cerebrovascular syndromes. International Journal of Stroke. 2007; 2(1):47–50 [PubMed: 18705988]
4.: Ball WL. Telematics. Prehospital Emergency Care. 2006; 10(3):320–321 [PubMed: 16801270]
5.: Banitsas K, Perakis K, Koutsouris D, Konis G, Tachakra S. Ambulance 3G. Conference Proceedings. 2005; 1:371–374 [PubMed: 17282191]
6.: Banitsas KA, Perakis K, Tachakra S, Koutsouris D. Use of 3G mobile phone links for teleconsultation between a moving ambulance and a hospital base station. Journal of Telemedicine and Telecare. 2006; 12(1):23–26 [PubMed: 16438775]
7.: Barrett KM, Pizzi MA, Kesari V, TerKonda SP, Mauricio EA, Silvers SM et al. Ambulance-based assessment of NIH Stroke Scale with telemedicine: a feasibility pilot study. Journal of Telemedicine and Telecare. 2016; [PubMed: 27177870]
8.: Beauchamp G, Phrampus P, Guyette FX. Simulated rescue airway use by laypersons with scripted telephonic instruction. Resuscitation. 2009; 80(8):925–929 [PubMed: 19481853]
9.: Benger JR, Karlsten R, Eriksson B. Prehospital thrombolysis: lessons from Sweden and their application to the United Kingdom. Emergency Medicine Journal. 2002; 19(6):578–583 [PMC free article: PMC1756299] [PubMed: 12421797]
10.: Bergrath S, Czaplik M, Rossaint R, Hirsch F, Beckers SK, Valentin B et al. Implementation phase of a multicentre prehospital telemedicine system to support paramedics: feasibility and possible limitations. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2013; 21:54 [PMC free article: PMC3710491] [PubMed: 23844941]
11.: Bergrath S, Reich A, Rossaint R, Rortgen D, Gerber J, Fischermann H et al. Feasibility of prehospital teleconsultation in acute stroke-a pilot study in clinical routine. PloS One. 2012; 7(5):e36796 [PMC free article: PMC3356340] [PubMed: 22629331]
12.: Bergrath S, Rortgen D, Rossaint R, Beckers SK, Fischermann H, Brokmann JC et al. Technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service - an observational study. Journal of Telemedicine and Telecare. 2011; 17(7):371–377 [PubMed: 21933897]
13.: Birati EY, Malov N, Kogan Y, Yanay Y, Tamari M, Elizur M et al. Vigilance, awareness and a phone line: 20 years of expediting CPR for enhancing survival after out-of-hospital cardiac arrest. The ‘SHL’-Telemedicine experience in Israel. Resuscitation. 2008; 79(3):438–443 [PubMed: 18952353]
14.: Botker MT, Stengaard C, Andersen MS, Sondergaard HM, Dodt KK, Niemann T et al. Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2016; 24(1):15 [PMC free article: PMC4751637] [PubMed: 26872739]
15.: Brouns R, Espinoza AV, Smedt A, Moens M, Hubloue I, Neyrinck S. Prehospital stroke study at the Universitair Ziekenhuis Brussel: preliminary data on 24/7 ambulance telemedicine for emergency stroke care. International Journal of Stroke. 2015; 10:(Suppl 2):422
16.: Buscher C, Elsner J, Schneiders MT, Thelen S, Brodziak T, Seidenberg P et al. The Telemedical Rescue Assistance System “TemRas”-development, first results, and impact. Biomedizinische Technik Biomedical Engineering. 2014; 59(2):113–123 [PubMed: 24445230]
17.: Bussieres S, Tanguay A, Hebert D, Fleet R. Unite de Coordination Clinique des Services Prehospitaliers d’Urgence: a clinical telemedicine platform that improves prehospital and community health care for rural citizens. Journal of Telemedicine and Telecare. 2016; [PubMed: 27072126]
18.: Cabrera MF, Arredondo MT, Quiroga J. Integration of telemedicine into emergency medical services. Journal of Telemedicine and Telecare. 2002; 8:(Suppl 2):12–14 [PubMed: 12217117]
19.: Cho SJ, Kwon IH, Jeong J. Application of telemedicine system to prehospital medical control. Healthcare Informatics Research. 2015; 21(3):196–200 [PMC free article: PMC4532845] [PubMed: 26279957]
20.: Cicero MX, Walsh B, Solad Y, Whitfill T, Paesano G, Kim K et al. Do you see what I see? Insights from using google glass for disaster telemedicine triage. Prehospital and Disaster Medicine. 2015; 30(1):4–8 [PubMed: 25571779]
21.: Correa BSPM, Goncalves B, Teixeira IM, Gomes ATA, Ziviani A. AToMS: a ubiquitous teleconsultation system for supporting AMI patients with prehospital thrombolysis. International Journal of Telemedicine and Applications. 2011; 2011:560209 [PMC free article: PMC3134102] [PubMed: 21772839]
22.: Criss EA. Link to the future: EMS-based telemedicine. JEMS. 2002; 27(10):74–81 [PubMed: 12368768]
23.: Curry GR, Harrop N. The Lancashire telemedicine ambulance. Journal of Telemedicine and Telecare. 1998; 4(4):231–238 [PubMed: 10505360]
24.: Czaplik M, Bergrath S, Rossaint R, Thelen S, Brodziak T, Valentin B et al. Employment of telemedicine in emergency medicine. Clinical requirement analysis, system development and first test results. Methods of Information in Medicine. 2014; 53(2):99–107 [PubMed: 24477815]
25.: Dietrich M, Walter S, Ragoschke-Schumm A, Helwig S, Levine S, Balucani C et al. Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial. Cerebrovascular Diseases. 2014; 38(6):457–463 [PubMed: 25531507]
26.: Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski M et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA - Journal of the American Medical Association. 2014; 311(16):1622–1631 [PubMed: 24756512]
27.: Espinoza AV, Van Hooff RJ, De Smedt A, Moens M, Yperzeele L, Nieboer K et al. PreSSUB II: The prehospital stroke study at the Universitair Ziekenhuis Brussel II. Journal of Translational Internal Medicine. 2015; 3(2):57–63 [PMC free article: PMC4936443] [PubMed: 27847888]
28.: Fakhraldeen M, Segal E, de Champlain F. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. Canadian Journal of Emergency Medicine. 2015; 17(6):709–712 [PubMed: 26012878]
29.: Felzen M, Brokmann JC, Beckers SK, Czaplik M, Hirsch F, Tamm M et al. Improved technical performance of a multifunctional prehospital telemedicine system between the research phase and the routine use phase - an observational study. Journal of Telemedicine and Telecare. 2016; [PubMed: 27080747]
30.: Gagliano D. Wireless ambulance telemedicine may lessen stroke morbidity. Telemedicine Today. 1998; 6(1):22 [PubMed: 10178357]
31.: Grim PS, Feldman T, Childers RW. Evaluation of patients for the need of thrombolytic therapy in the prehospital setting. Annals of Emergency Medicine. 1989; 18(5):483–488 [PubMed: 2719359]
32.: Hara T, Nishizuka T, Yamamoto M, Iwatsuki K, Natsume T, Hirata H. Teletriage for patients with traumatic finger injury directing emergency medical transportation services to appropriate hospitals: a pilot project in Nagoya City, Japan. Injury. 2015; 46(7):1349–1353 [PubMed: 25799472]
33.: Hsieh JC, Lin BX, Wu FR, Chang PC, Tsuei YW, Yang CC. Ambulance 12-lead electrocardiography transmission via cell phone technology to cardiologists. Telemedicine Journal and E-Health. 2010; 16(8):910–915 [PubMed: 20925562]
34.: Hubert GJ, Muller-Barna P, Audebert HJ. Recent advances in TeleStroke: a systematic review on applications in prehospital management and Stroke Unit treatment or TeleStroke networking in developing countries. International Journal of Stroke. 2014; 9(8):968–973 [PubMed: 25381687]
35.: Itrat A, Taqui A, Cerejo R, Briggs F, Cho SM, Organek N et al. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurology. 2016; 73(2):162–168 [PubMed: 26641366]
36.: Joanna MB, Duncan R, David R, Kenneth R. An alternative model of pre-hospital care for 999 patients who require non-emergency medical assistance. International Journal of Emergency Services.: Emerald. 2017; 6(2):99–103
37.: Kawakami S, Tahara Y, Noguchi T, Yagi N, Kataoka Y, Asaumi Y et al. Time to reperfusion in ST-segment elevation myocardial infarction patients with vs. without pre-hospital mobile telemedicine 12-lead electrocardiogram transmission. Circulation Journal. 2016; 80(7):1624–1633 [PubMed: 27250917]
38.: Keane MG. A review of the role of telemedicine in the accident and emergency department. Journal of Telemedicine and Telecare. 2009; 15(3):132–134 [PubMed: 19364895]
39.: Krumperman K, Weiss S, Fullerton L. Two types of prehospital systems interventions that triage low-acuity patients to alternative sites of care. Southern Medical Journal. 2015; 108(7):381–386 [PubMed: 26192931]
40.: Langabeer JR, Gonzalez M, Alqusairi D, Champagne-Langabeer T, Jackson A, Mikhail J et al. Telehealth-enabled emergency medical services program reduces ambulance transport to urban emergency departments. Western Journal of Emergency Medicine. 2016; 17(6):713–720 [PMC free article: PMC5102597] [PubMed: 27833678]
41.: Liman TG, Winter B, Waldschmidt C, Zerbe N, Hufnagl P, Audebert HJ et al. Telestroke ambulances in prehospital stroke management: concept and pilot feasibility study. Stroke. 2012; 43(8):2086–2090 [PubMed: 22693132]
42.: Lippman JM, Smith SNC, McMurry TL, Sutton ZG, Gunnell BS, Cote J et al. Mobile telestroke during ambulance transport is feasible in a rural EMS setting: the iTREAT study. Telemedicine Journal and E-Health. 2016; 22(6):507–513 [PMC free article: PMC5898765] [PubMed: 26600433]
43.: Mandellos GJ, Lymperopoulos DK, Koukias MN, Tzes A, Lazarou N, Vagianos C. A novel mobile telemedicine system for ambulance transport. Design and evaluation. Conference Proceedings. 2004; 4:3080–3083 [PubMed: 17270929]
44.: Morrison J, Shrestha NR, Hayes B, Zimmerman M. Mobile phone support for rural health workers in Nepal through ‘celemedicine’. Journal of the Nepal Medical Association. 2013; 52(191):538–542 [PubMed: 24907968]
45.: Nagata I, Abe T, Nakata Y, Tamiya N. Factors related to prolonged on-scene time during ambulance transportation for critical emergency patients in a big city in Japan: a population-based observational study. BMJ Open. 2016; 6(1):e009599 [PMC free article: PMC4716242] [PubMed: 26729386]
46.: Nordberg M. Remote control. Telemedicine revolutionizes EMS in rural America. Emergency Medical Services. 1996; 25(8):39–45 [PubMed: 10159377]
47.: Nordberg M. Taking it to the streets: telemedicine update. Emergency Medical Services. 1999; 28(8):37–40 [PubMed: 10539563]
48.: Papai G, Racz I, Czuriga D, Szabo G, Edes IF, Edes I. Transtelephonic electrocardiography in the management of patients with acute coronary syndrome. Journal of Electrocardiology. 2014; 47(3):294–299 [PubMed: 24636796]
49.: Pedley DK, Beedie S, Ferguson J. Mobile telemetry for pre-hospital thrombolysis: problems and solutions. Journal of Telemedicine and Telecare. 2005; 11:(Suppl 1):78–80 [PubMed: 16036004]
50.: Raaber N, Botker MT, Riddervold IS, Christensen EF, Emmertsen NC, Grofte T et al. Telemedicine-based physician consultation results in more patients treated and released by ambulance personnel. European Journal of Emergency Medicine. 2016; [PubMed: 27755124]
51.: Terkelsen CJ, Norgaard BL, Lassen JF, Gerdes JC, Ankersen JP, Romer F et al. Telemedicine used for remote prehospital diagnosing in patients suspected of acute myocardial infarction. Journal of Internal Medicine. 2002; 252(5):412–420 [PubMed: 12528759]
52.: Wendt M, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE et al. Improved prehospital triage of patients with stroke in a specialized stroke ambulance results of the pre-hospital acute neurological therapy and optimization of medical care in stroke study. Stroke. 2015; 46(3):740–745 [PubMed: 25634000]
53.: Yperzeele L, Van Hooff RJ, De Smedt A, Valenzuela Espinoza A, Van Dyck R, Van de Casseye R et al. Feasibility of AmbulanCe-based Telemedicine (FACT) study: safety, feasibility and reliability of third generation in-ambulance telemedicine. PloS One. 2014; 9(10):e110043 [PMC free article: PMC4208882] [PubMed: 25343246]
54.: Zanini R, Aroldi M, Bonatti S, Buffoli F, Izzo A, Lettieri C et al. Impact of prehospital diagnosis in the management of ST elevation myocardial infarction in the era of primary percutaneous coronary intervention: reduction of treatment delay and mortality. Journal of Cardiovascular Medicine. 2008; 9(6):570–575 [PubMed: 18475124]

Appendices

Appendix A. Review protocol

Table 2Review protocol: Ambulance staff remote access to clinical advice

Review question: Does the provision of immediate access by ambulance staff to clinical advice, using remote decision support reduce NHS resource usage and improve outcomes?
Objective	To determine if immediate access by ambulance staff to senior decision makers improves outcomes and NHS resources.
Rationale	The first point of contact with an emergency referral is associated with the highest level of uncertainty. Paramedic ambulance staff are well-trained to handle uncertainty but may need time to arrive at a binary decision to continue treatment at home or transfer the patient to hospital. This decision may be reached faster, or more securely, if it is made with the support of specialist advice, accessed using remote technologies or telephone consultations.
Population	Adults and young people (16 years and over) with a suspected AME.
Intervention	Independent paramedic decision making (transport to ED or advice at scene only): Standard paramedics Advanced paramedics with additional post registration training (for example, paramedic practitioner or emergency care practitioner).
Comparison	Remote expert-supported paramedic decision making including: Telephone consultations Telemedicine systems.
Outcomes	Number of patients seeking further contacts after initial assessment by paramedic (GP, 999, ED or 111) OR Re-contact rates within 72 hours (CRITICAL) Health-related quality of life (CRITICAL) Mortality (CRITICAL) Conveyance (carriage) rates (CRITICAL) Total avoidable adverse events as reported by the study (CRITICAL) Patient satisfaction (CRITICAL) Number of hospital admissions (IMPORTANT) Staff satisfaction(IMPORTANT)
Exclusion	-
Search criteria	The databases to be searched are: Medline, Embase, the Cochrane Library. Date limits for search: No date limits. Language: English only.
The review strategy	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Analysis	Data synthesis of RCT data or observational study data (as appropriate). Meta-analysis where appropriate will be conducted. Studies in the following subgroup populations will be included: Frail elderly. In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.
Key papers	-
Number of clinical questions	-

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of paramedic remote access to clinical advice

Appendix C. Forest plots

No relevant clinical evidence identified.

Appendix D. Clinical evidence tables

No relevant clinical evidence identified.

Appendix E. Economic evidence tables

No studies were included.

Appendix F. GRADE tables

No relevant clinical evidence identified.

Appendix G. Excluded clinical studies

Table 3Studies excluded from the clinical review

Study	Reason for exclusion
Abrashkin 2016¹	No relevant outcomes
Adeyinka 1996²	Review article detailing the development of tele-ambulance workstations
Amarenco 2007³	Incorrect intervention (video conferencing patients to aid diagnosis)
Ball 2006⁴	Article with no data to present
Banitsas 2005⁵	Looks at the technology and operational side of telemedicine
Banitsas 2006⁶	No outcomes of interest
Barrett 2016⁷	No relevant outcomes
Beauchamp 2009⁸	Incorrect intervention (those with no medical training instructed using a telephone-directed protocol to assess airway placement
Benger 2002⁹	Descriptive paper only
Bergrath 2011¹²	Looks at the technology and operational side of telemedicine
Bergrath 2012¹¹	EMS physician present in ambulance. No outcomes of interest
Bergrath 2013¹⁰	No outcomes of interest
Birati 2008¹³	Telemedicine to instruct patients to perform CPR
Bøtker 2016¹⁴	Incorrect comparison – types of symptoms
Brouns 2015¹⁵	Abstract only
Buscher 2014¹⁶	Looks at the technology and operational side of telemedicine
Bussiéres 2016¹⁷	Incorrect comparison; no relevant outcomes
Cabrera 2002¹⁸	Economic evaluation
Cho 2015¹⁹	No extractable outcomes
Cicero 2015²⁰	No outcomes of interest
Correa 2011²¹	Test run of telemedicine focusing on operational side
Criss 2002²²	Magazine article. No data presented
Curry 1998²³	Review of the implementation of telemedicine
Czaplik 2014²⁴	Review of the requirements for the use of telemedicine
Dietrich 2014²⁵	Economic evaluation
Ebinger 2014²⁶	No telemedicine
Espinoza 2015²⁷	Study protocol
Fakhraldeen 2016²⁸	Incorrect intervention - does not constitute ‘remote’ support
Felzen 2016²⁹	No relevant outcomes
Gagliano 1998³⁰	Magazine article
Grim 1989³¹	Attempts to justify the need for telemedicine
Hara 2015³²	No extractable outcomes
Hsieh 2010³³	Looks at the technology and operational side of telemedicine
Hubert 2014³⁴	No outcomes of interest
Itrat 2016³⁵	No extractable outcomes
Joanna 2017³⁶	This is an article which discussed one scheme where the paramedics were trained to refer patients to a GP service. Incorrect study design, inappropriate intervention, no comparison group.
Kawakami 2016³⁷	Different system which was not applicable to UK practice
Keane 2009³⁸	Incorrect intervention (telemedicine in the ED)
Krumperman 2015³⁹	No extractable outcomes
Langabeer 2016⁴⁰	Different system which was not applicable to UK practice
Liman 2012⁴¹	Tele medicine prototype and its feasibility
Lippman 2016⁴²	No relevant outcomes
Mandellos 2004⁴³	Looks at the technology and operational side of telemedicine
Morrison 2013⁴⁴	Incorrect population (rural area and mid-level health care workers)
Nagata 2016⁴⁵	Incorrect intervention – time at scene
Nordberg 1996⁴⁶	Report on telemedicine; no data presented
Nordberg 1999⁴⁷	Updated report on telemedicine; no data presented
Papai 2014⁴⁸	Different system which was not applicable to UK practice
Pedley 2005⁴⁹	Looks at the technology and operational side of telemedicine
Raaber 2016⁵⁰	Different system which was not applicable to UK practice
Terkelsen 2002⁵¹	No outcomes of interest
Wendt 2015⁵²	Different system which was not applicable to UK practice
Yperzeele 2014⁵³	Looks at the technology and operational side of telemedicine
Zanini 2008⁵⁴	Different system which was not applicable to UK practice

Appendix H. Excluded economic studies

Reference

Reason for exclusion

Dietrich 2014²⁵

This study was assessed as not applicable. The study compares a mobile stroke unit to an ambulance; hence, telemedicine/remote support is not the only difference between the intervention and the comparator. There is some uncertainty regarding the applicability of data on resource use and costs from Germany to current UK NHS context. QALYs were not assessed, as only costs were compared. Estimates of relative effectiveness are obtained from a study that compared a fully equipped mobile stroke unit to conventional stroke treatment.

Tables

Table 1PICO characteristics of review question

Population	Adults and young people (16 years and over) with a suspected AME.
Intervention(s)	Independent paramedic decision making (transport to ED or advice at scene only): Standard paramedics Advanced paramedics with additional post registration training (for example, paramedic practitioner or emergency care practitioner).
Comparison(s)	Remote expert-supported paramedic decision making including: Telephone consultations Telemedicine systems.
Outcomes	Number of patients seeking further contacts after initial assessment by paramedic (GP, 999, ED, 111) OR Re-contact rates within 72 hours (CRITICAL) Quality of life (CRITICAL) Mortality (CRITICAL) Conveyance (carriage) rates (CRITICAL) Total avoidable adverse events as reported by the study (CRITICAL) Patient satisfaction (CRITICAL) Number of hospital admissions (IMPORTANT) Staff satisfaction (IMPORTANT)
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.

Bookshelf ID: NBK564931

Contents

< Prev Next >