Conclusions
The TEMS trial demonstrated the non-inferiority of the tele-EMS combined with quality improvement if the tele-EMS physician was involved. The findings suggest a benefit of the tele-EMS for the limited conventional EMS physician resource, supporting further implementation of the tele-EMS as an additional structure in countries with a conventional physician-based EMS. This approach would allow paramedics to be dispatched alone with the possibility to contact a tele-EMS physician at any time for severe conditions, and on-site EMS physicians for acute life-threatening emergencies with the potentially need for manual skills on scene. Further national and international multicentre studies are needed to confirm our results.