Discussion
SECONDARY, EMERGENCY, EVENT
In this RCT, we revealed that prehospital emergency care using a tele-EMS is non-inferior to the conventional physician-based EMS in severe but not acute life-threatening emergencies in the occurrence of intervention-related AEs with causality to the group assignment. Moreover, patients in the tele-group could be managed by the paramedics alone in 58% of all cases. If a physician was deemed necessary and became involved, the tele-EMS physician was superior in terms of several secondary outcomes, as he/she gets the diagnostic/therapeutic guideline and disease-specific SOP displayed on screen and hence is not at risk of missing anything basic.With a new German Emergency Paramedic law passed in 2014, competencies for paramedics without an EMS-physician on site were permitted, which were previously prohibited by law. A relevant decrease in the use of EMS-physicians with regard to severe missions is only expected in the future, since not all paramedics have been trained or feel save accordingly. Nevertheless, the consultation of a tele-EMS-physician can provide low-threshold support for the paramedics in the event of problems, since not all assignments can be mapped in the form of SOPs. With the current level of training of the paramedics of a Franco-German EMS system [Although not outcome relevant, the time span between the emergency call and arrival at the hospital was shorter with patients treated by a conventional physician-based EMS than those with tele-EMS. Nevertheless, a complete “SAMPLE”-anamnesis combined with a telephone pre-registration by the tele-EMS-physician helps to speed up further treatment in the hospital [To our best knowledge, this is the first large RCT to compare tele-EMS with conventional EMS for severe but not acute life-threatening cases within a municipal EMS routine. Previous studies were either non-randomised [Our results demonstrated that even though the paramedics cancelled the tele-EMS physician involvement in 58% of the emergency cases, the emergency care in this tele-EMS was safe without significantly more AEs. Interestingly, the threshold for cancellation of physician involvement by paramedics was significantly higher in the control group, while the severity and type of cases were similar in both groups. This is because of that the conventional EMS physician arrived in 293 and 455 cases before and in parallel with the paramedics on scene, respectively. In the remaining cases, the mean time difference was only 4:51 min, which impeded the paramedics to adequately evaluate the emergency before the physician arrived. Contrary, in the tele-group the tele-EMS physician was always available by pushing a button and does not drive to scene; tele-EMS physician was only not cancelled, if there was real medical necessity. Hence, primary dispatching of tele-EMS for severe emergencies does not withhold the legally prescribed EMS-physician but might save the limited resources of a conventional EMS physician and allow focused dispatching of conventional EMS physicians to acute life-threatening emergencies [A higher quality and shorter physician engagement time for the complementarily used tele-EMS physician was previously shown [The TEMS trial demonstrated safe, feasible, and high-quality patient-centred use of telemedicine in prehospital emergency settings, which might be relevant and quality improving for all EMS systems [