NOAH – A Mobile Emergency Care System

U. Schächinger1, R. Kretschmer2, W. Röckelein1, C. Neumann1, M. Maghsudi1, M. Nerlich1

  1. University of Regensburg Medical Centre, Dept. of Trauma Surgery, 
    Franz-Josef-Strauß-Allee 11, 93042 Regensburg, Germany
  2. Centre for Health Care Quality of Missouri – Columbia, Columbia, MO, USA

Abstract:

Experiencing communication problems in our emergency services, we developed an innovative communication network and system – the NOAH-system (NOAH, which stands for Notfall -, Organisations - und Arbeitshilfe or Emergency-Organisation Active Aide System). In contrast with the currently established emergency services communication in Germany by radio wave, data is transferred from the scene in the form of an electronic record on a mobile computer by means of the wireless data communication network Modacom (Mobile Data Communication), which is provided by German Telekom. It is received at the dispatch-centre in mentioned format and transferred to the admitting hospital without any loss of data.

In a prospective study, the technical and conceptual suitability of this system was investigated. It was shown that an admitting hospital was informed more than 20 minutes in advance about the admittance of a patient. To assure the quality of transferred data, information was ranked by different criteria. This further demonstrated that much more precise information about a patient`s condition was already available upon admittance in the hospital.

Key words:
emergency care, telematics, mobile computing, data communication, medical documentation 


1. Introduction

Emergencies occur anywhere, at any location, at any time, and in various different ways - thus making any one of us susceptible.

Although the structure of the emergency care systems differ across nations, the aims in applying emergency medical services are worldwide
the same:

To reach these aims, the Federal Republic of Germany affords a very sophisticated emergency care system. The emergency medical services in Germany are provided by ambulance cars, vehicular emergency life support, and by helicopter - making it one of the best systems world-wide [10]. In allmost all serious medical emergencies, an emergency phsyician on scene is alerted in addition to paramedics. The paramedics and on-scene-physicians are specially trained regarding emergency medicine and their medical equipment is highly advanced; this is why a German ambulance car or helicopter is sometimes dubbed a „Mobile Intensvie Care Unit“ . 

Due to technical and medical progress during the last few years and continued efforts to increase educational guidance for emergency physicians, emergency medical services have significantly improved. Despite good overall medical care, however, we have identified some weak points and points of non-conformance in the single phase of the rescue course which subject the patient to avoidable life-threatening situations [7,8,9]. As an example, we find that an inadequate shock treatment facilitates development of post-traumatic multiple-organ-dysfunction, which threatens the patient’s life even days after an accident. On the other hand, an improperly attended injury can lead to a life-long disability with secondary effects in reference to social and economical problems.

Therefore, the demands placed upon any rescue system are to reduce the therapy-free time intervals as much as possible, and to provide the emergency physician with the means required to foster optimal care.

Whereas physicians in the hospital environment are used to working on a team and can cross-reference with others, the emergency physician on the scene is confined to make his decision without the usual diagnostics. His basic knowledge has to handle specific emergencies on various specialities from gynaecology and obstetrics, to paediatrics, internal medicine, surgery, and others. In case of an accident, the physician additionally has to cover managerial functions, from the initial scene analysis to timely requests for additional rescue devices, as well as the choice for the proper hospital.

This procedure must be accompanied by complete, easy to evaluate, and transparent documentation [2,3,5].

While the medical and technical progress in the field of emergency medicine has been developed ( e.g., lyse-therapy on acute myocardial infarctions or a new defibrillator) with considerable financial and investigative efforts, data communication and scene handling, as well as managerial functions, are comparatively underdeveloped. Primarily in the area of data communication, technical and managerial functions seem to be nearly unexplored [7,8,9].

We must therefore make an effort to optimise the information flow from the initial emergency call to the admitting hospital. Currently, communication between the emergency physician or ambulance and the dispatch-centre occurs wireless, using reserved radio frequencies (BOS-radio). Experienced communication problems are due to technical and system-related inadequacies, such as radio shadows (communication dead space), or the simultaneous use of different frequencies by the emergency physician/ambulance, fire-brigade, and police.

While the use of existing direct frequencies has improved data communication regionally, this method entailes considerable financial and technical efforts, and is therefore not widely used. It is the case now, as it has been before, that only one operator can communicate on any given channel at one time. The information flow also remains unchanged, dispersing unscreened and unstructured information to the operator in the dispatch-centre. This will inform the operator of the emergency physician’s/ambulance location and their status, as well as additional information about other required rescue systems or special fire-brigades. This condition may foster the loss of information, or cause a delay in passing the medical condition to the admitting hospital, as experienced in the children’s game “silent mail” [8,9].

At the present time, it is very difficult for the on-scene rescue team to obtain quick and secure information in selecting the most advantageous hospital. This also means that the admitting hospital is not properly informed about the incoming patient.

Upon admission to the hospital, the patient should be treated carefully, effectively, and spontaneously by a pre-informed and thoroughly prepared team in the shock room.

Incomplete (or lack of) incoming patient information for the admitting hospital leads uneconomical usage of resources in cases of overestimation, and to damage to the patient in cases of underestimation. 

Time loss in data communication in reference to time-sensitive situations - such as severely injured patients, inter-cerebral haemorrhaging, myocardial infarction or poisoning - are not acceptable. These evident deficits in the intersection between rescue system and hospital have sparked headlines declaring “tourism of emergencies”.

Our primary effort should therefore be concentrated on optimising the information-flow for all links within the rescue chain, starting at the emergency call and proceeding to the admitting hospital. Our goals are to specifically control available rescue-devices by means of improved communication technology, to inform the on-scene emergency physician of the availability of free regional capabilities, and lastly to standardise patient reporting. 

Solution-approaches on improving the rescue system:

Given those negative headlines and problems encountered daily based in practical experience, (e.g., having no or false information about the injuries of an incoming patient), prompted our Department of Trauma-Surgery at Regensburg University and the Rescue-Centre Regensburg to develop an innovative communication network and co-ordination system called the Emergency-Organisation Active Aide System or NOAH-projekt (NOAH, Notfall -, Organisations - und Arbeitshilfe) [8,9].

NOAH’s solution approach focuses on improving the communication link from the emergency ambulance to the hospital and dispatch-centre by electronic data transfer.


2. Materials and Methods

The requirements for the new communication technology encompasses the following merits: 

This means: using notepad-generated patient identification cards, making individual data accessible prior to admission, negating repeated record creating and processing.

The notepad-computer currently used is the „FORTÉ Wireless CommPad®“ from Motorola, Israel. It features a backlit VGA-compatible LCD display with a pen-based interface, an internal radio-modem for data-networks using the RD-LAP (Radio Data Link Access Protocol) protocol, a exchangeable internal battery providing 4 to 8 hours of operation, a 486DX processor and a vehicle docking station. It is operational in wide temperature/humidity range and has a shock-proof water-resistant design (e.g., withstands a four-foot drop). A close-up under winter-conditions is shown in figure 1.


[Figure 1: FORTÉ Wireless CommPad]

Current developments incorporate a mobile-computer in the on-scene-physicians vest, eliminating the need for an extra item to carry to the emergency scene. The NOAH-Vest employs the Xybernaut MA IV® (Figure 2). It features a touch-sensitive Flat-Panel-Display on the left sleeve of the vest. The other MA IV’s components are distributed in the vest, making the weight hardly noticable. Another advantage of the Xybernaut computer is that it has enough CPU power for the next additions to the NOAH-System: Voice-Control, transmission of still pictures from the emergency scene and GPS-based location of the on-scene physician in the dispatch center.


[Figure 2: Xybernaut MA IV, integrated in a EMS-Vest]

Specifically, improvement of the pre-hospital to hospital process is achieved by using the mobile computer loaded with an electronic version of the German Society of Intensive Care and Emergency Medicine (DIVI) standardised emergency report [2, 5], and the use of mobile data transfer via the wireless data communication network Modacom (Mobile Data Communication), which is provided by German Telekom and employes the RD-LAP 9.6 protocol. 

The NOAH software has been developed by an interdisciplinary team consisting of on-scene-physicians, trauma surgeons, MIS faculty members and programmers from the company „Kratzer Communications, Munich“, an expert in wireless vehicle management solutions. The software has been developed for a standard PC platform and runs under Windows 3.1 or Windows 95/98/NT.

The two methods mentioned above assist in improving the communication flow between the on-scene occurrence and the dispatch-centre. Within a few seconds, bi-directional data transfer and synchronisation with up to 1000 other participants is possible.  
After an emergency call reaches the dispatch centre, the dispatcher feeds the emergency instructions (e.g., the kind of emergency, location, and so on) in the dispatch centre`s computer system; the NOAH-communication-terminal at the dispatch centre will automatically forward this information to the mobile-computer of the alerted EMS. The respective actual EMS-status, e.g., departure or arrival at the scene, is transfered to the dispatch centre by using the notepad`s shortcut EMS-status-messaging-buttons.

Upon arrival at the scene, the emergency physician feeds the notepad-computer with important information linking age, sex, emergency category, and initiated corrective action - such as intubation - and sends this data to the dispatch-centre by a ”fire and forget” method. Figure 3 shoes the screen interface which is used to put the so called “first-sight information” into the computer.


[Figure 3: First-sight Information Interface. Important Information are fed in the notepad-computer upon arrival at the scene.]

With this data, the dispatch-centre can pre-select the admitting hospital in advance by submitting significant details. Another advantage is provided through automatic documentation recording and its selective information flow. This can be especially helpful during disasters, when hopeless communication confusion on different radio waves channels is experienced.


3. Results

The results of our studies can be summarised as follows. The usage of the NOAH system is practicable. First-sight information can be fed in less than 15 seconds, and entirely submitted within the first three minutes after arrival at the scene. This data is available at the dispatch-centre only a few seconds after its initial submission, and is available only a few minutes later at the admitting hospital, too. Practical application of this system showed a significant improvement in time (Figure 4) and information processing, and was achieved through quantified information ranking (Figure 5).


[Figure 4: Information Level at the admitting hospital during emergency treatment at the scene and patient transfer]


[Figure 5: Comparison of preparation time in the admitting hopital with BOS and NOAH]

The admitting hospital was immediately and thoroughly informed of the incoming patient. There was an average time saving of more then 20 minutes in comparison to conventional data transfer (BOS-radio), a distinct – most likely life saving – advantage.


4. Discussion

Using the NOAH-system first of all involves quite a different way of information management handling during an emergency (Figure 6). Because of the well-structured data transfer (first-sight information) to the dispatch centre only a short time after arrival on the scene, the dispatch-centre is able to pre-select and inform an admitting hospital while the emergency patient is being treated at the scene (parallel information management). Using conventional data transmission via BOS-radio involves serial information management, because transferring information to the dispatch-centre happens after finishing the initial treatment of the patient normally.



[Figure 6: Emergency Management – Information Management]

This additional time at an admitting hospital may be used to inform all needed specialists in the hospital, and to prepare for the following situations: 

High quality pre-information and high accuracy of this information reduce the wait, and see strategies consequently leading to time conformance and properly taken action.

In addition to communication facilitation and documentation, the properly programmed mobile-computer enables the flawless deposit of medical information and algorithms for specific emergencies (e.g., poisoning), and could lead to additional improvement in the quality of medical service provided on the scene.

The total concept of a multi-medial communication network in Eastern Bavaria is outlined in Figure 7. The concept is not limited only to emergency care, but also includes aspects of telemedicine. The expanding network of hospitals and practitioners has the capacity to increase the quality of health care.


[Figure7: Eastern Bavaria Telemedicine and Emergency Care Communication Network]

Opportunity link of outcome research:

This project could impressively demonstrate the effectiveness of the NOAH concept, which reduces the pre-clinical interval and improves flow and content of information, via:

It is most important to define the medical advantage produced by this innovative application. This innovative concept shows ways to save lives, to prevent invalidity, and to improve quality of life. Statistics measuring reduction of deaths and invalidity are constantly recorded in extensive analysis projects. The NOAH-concept is currently undergoing a scientific and statistical validation program in Eastern Bavaria. It is necessary to measure the direct, indirect and intermediate use now [6].


5. References

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  2. DIVI. Das bundeseinheitliche Notarzteinsatzprotokoll der Deutschen Interdisziplinären Vereinigung für Intensiv- and Notfallmedizin (DIVI).
    Notarzt 1989; 5: 91
  3. Donabedian A. The quality of medical care. Methods of assessing and monitoring the quality of care for research and quality assurance
    programs. Science 1978; 200: 856
  4. Essin DJ, Essin CD. Computerized medical records: Software criteria for systems to document patient encounters. Critical Care
    Medicine 1990; 18: 100
  5. Friedrich HJ, Messelken M. Der minimale Notarztdatensatz (MIND). Notarzt 1996,12:186
  6. Lobley D. The economics of telemedicine. Journal of Telemedicine and Telecare 1997, 3(3):117
  7. Maier R, Röckelein W. An Inter-Organisational System to Support Emergency Care Process Chains - The NOAH Project. Universität
    Regensburg, Lehrstuhl für Wirtschaftsinformatik III, 1999
  8. Nerlich M et al. . Neue Kommunikationstechnologien in der Notfallmedizin. Rettungszentrum Regensburg, 1996
  9. Schächinger U, Stieglitz SP, Kretschmer R, Nerlich M. Telemedizin und Telematik in der präklinischen Notfallmedizin. Notfall- und
    Rettungsmedizin 1999, 2(8): 468
  10. Trunkey DD. Society of Universal Surgeons. Presidential address: On the nature of things that go bang in the night. Surgery 1982; 92(2):
    123-32

Address for correspondence:

U. Schächinger
Dept. of Trauma Surgery
University of Regensburg Medical Centre
Franz-Josef-Strauß-Allee 11
93042 Regensburg, Germany
Tel. +49 (0)941-944-6805
Fax +49 (0)941-944-6806
e-mail: ulrich.schaechinger@klinik.uni-regensburg.de