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Background: Tele-emergency physicians (TEPs) take an increasingly important role in the need-oriented provision of emergency patient care. To improve emergency medicine in rural areas, we set up the project Land|Rettung (English: Rural|Rescue), which uses TEPs to restructure professional rescue services using information and communication technologies (ICTs) in order to reduce the therapy-free interval. Successful implementation of ICTs relies on user acceptance and knowledge sharing behavior. Methods and findings: We conducted a factorial design with active knowledge transfer and technology acceptance as a function of work satisfaction (high vs. low), workload (high vs. low) and point in time (prior to vs. after digitalization). Data were collected via machine readable questionnaires issued to 755 persons (411 pre, 344 post), of which 304 or 40.3% of these persons responded (194 pre, 115 post).Technology acceptance was higher after the implementation of TEP for nurses but not for other professional groups, and it was higher when the workload was high. Regarding active communication and knowledge sharing, employees with low work satisfaction are more likely to share their digital knowledge as compared to employees with high work satisfaction. Additional and more detailed analyses reveal that this is an effect of previous knowledge concerning digitalization. After implementing the new technology, work satisfaction increased for the more experienced employees, but not for the less experienced ones. Results are discussed considering the Dunning-Kruger effect. The Dunning-Kruger effect describes a cognitive bias. People with high expertise often underestimate their actual skill level. They have a more critical attitude towards their performance and feel the urgent need to fill possible knowledge gaps they notice. Conclusions: Our research illustrates that employees’ workload has an impact on the intention of using digital applications. The higher the workload, the more people are willing to use TEPs. Regarding active knowledge sharing, we see that employees with low work satisfaction are more likely to share their digital knowledge compared to employees with high work satisfaction. This might be attributed to the Dunning-Kruger effect. Highly knowledgeable employees initially feel uncertain about the change, which translates into temporarily lower work satisfaction. They feel the urge to fill even small knowledge gaps, which in return leads to higher work satisfaction. Those responsible need to acknowledge that digital change affects their employees’ workflow and work satisfaction. During such times, employees need time and support to gather information and knowledge in order to cope with digitally changed tasks.

BACKGROUND Tele-emergency physicians (TEP) take an increasingly important role in the need-oriented provision of emergency patient care. To improve emergency medicine in rural areas, we set up the project ‘Rural|Rescue’, which uses TEP to restructure professional rescue services using information and communication technologies (ICT) in order to reduce the therapy-free interval. Successful implementation ICT relies on user acceptance and knowledge sharing behavior. OBJECTIVE This study aims to show how changes in work load and job satisfaction influence knowledge sharing behavior and technology acceptance during introduction of ICT. METHODS We conducted a factorial design with active knowledge transfer and technology acceptance as a function of work satisfaction (high vs. low), work load (high vs. low) and point in time (prior to vs. after digitalization). Data were collected via machine readable questionnaires issued to 755 persons (411 pre, 344 post), of which 304 or 40.3% of these persons responded (194 pre, 115 post). RESULTS Technology acceptance was higher prior to digitalization than after the implementation of TEP. Also, technology acceptance was higher when the workload was low. Regarding the active knowledge sharing, employees with low work satisfaction are more likely to share their digital knowledge as compared to employees with high work satisfaction. Additional and more detailed analyses reveal that this is an effect of previous knowledge concerning digitalization. After implementing the new technology work satisfaction increased for the more experienced employees, but not for the less experienced ones. Results are discussed considering the Dunning-Kruger-effect. The Dunning-Kruger-effect describes a cognitive bias. People with pre-existing knowledge of the matter often underestimate their actual skill level. They have a more critical attitude towards their performance and feel the urgent need to fill possible knowledge gaps they notice. CONCLUSIONS Our research illustrates that employees’ work load has an impact on the intention using digital applications. The higher the work load, the less people are willing to use TEP. Regarding the active knowledge sharing, we see that employees with low work satisfaction are more likely to share their digital knowledge compared to employees with high work satisfaction. This might be attributed to the Dunning-Kruger-effect. Highly knowledgeable employees firstly feel uncertain about the alteration which translates in momentarily lower work satisfaction. They feel the urge for filling even small knowledge gaps which in return leads to higher work satisfaction. Those responsible need to acknowledge that digital change affects their employees’ workflow and work satisfaction. During those times, employees need time and support to gather information and knowledge in order to cope with digitally changed tasks. CLINICALTRIAL Ethical approval BB 044/17 from 21.03.2017, Ethics Commission University Medicine Greifswald INTERNATIONAL REGISTERED REPORT RR2-10.2196/14358

Background and objective Teleemergency doctors support ambulance cars at the emergency site by means of telemedicine. Currently, each district has its own teleemergency doctor office (decentralized solution). This paper analyses the advantages and disadvantages of a centralized solution where several teleemergency doctors work in parallel in one office to support the ambulances in more districts. Methods The service of incoming calls from ambulances to the teleemergency doctor office can be modelled as a queuing system. Based on the data of the district of Vorpommern-Greifswald in the Northeast of Germany, we assume that arrivals and services are Markov chains. The model has parallel channels proportionate to the number of teleemergency doctors working simultaneously and the number of calls which one doctor can handle in parallel. We develop a cost function with variable, fixed and step-fixed costs. Results For the district of Greifswald, the likelihood that an incoming call has to be put on hold because the teleemergency doctor is already fully occupied is negligible. Centralization of several districts with a higher number of ambulances in one teleemergency doctor office will increase the likelihood of overburdening and require more doctors working simultaneously. The cost of the teleemergency doctor office per ambulance serviced strongly declines with the number of districts cooperating. Discussion The calculations indicate that centralization is feasible and cost-effective. Other advantages (e.g. improved quality, higher flexibility) and disadvantages (lack of knowledge of the location and infrastructure) of centralization are discussed. Conclusions We recommend centralization of telemedical emergency services. However, the number of districts cooperating in one teleemergency doctor office should not be too high and the distance between the ambulance station and the telemedical station should not be too large.

Background Over the past decade Smartphone-based activation (SBA) of Community First Responders (CFR) to out-of-hospital cardiac arrests (OHCA) has gained much attention and popularity throughout Europe. Various programmes have been established, and interestingly there are considerable differences in technology, responder spectrum and the degree of integration into the prehospital emergency services. It is unclear whether these dissimilarities affect outcome. This paper reviews the current state in five European countries, reveals similarities and controversies, and presents consensus statements generated in an international conference with the intention to support public decision making on future strategies for SBA of CFR. Methods In a consensus conference a three-step approach was used: (i) presentation of current research from five European countries; (ii) workshops discussing evidence amongst the audience to generate consensus statements; (iii) anonymous real-time voting applying the modified RAND-UCLA Appropriateness method to adopt or reject the statements. The consensus panel aimed to represent all stakeholders involved in this topic. Results While 21 of 25 generated statements gained approval, consensus was only found for 5 of them. One statement was rejected but without consensus. Members of the consensus conference confirmed that CFR save lives. They further acknowledged the crucial role of emergency medical control centres and called for nationwide strategies. Conclusions Members of the consensus conference acknowledged that smartphone-based activation of CFR to OHCA saves lives. The statements generated by the consensus conference may assist the public, healthcare services and governments to utilise these systems to their full potential, and direct the research community towards fields that still need to be addressed.

Background German emergency medical services are a 2-tiered system with paramedic-staffed ambulances as the primary response, supported by prehospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply, whereas the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of the essence because, with each passing minute, the chance of survival with good neurological outcome decreases. Objective The project has 4 main objectives: (1) reduce the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (ie, bystander cardiopulmonary resuscitation), (2) provide faster professional first aid in addition to rescue services through alerting trained first aiders by mobile phone, (3) make more emergency physicians available more quickly through introducing the tele-emergency physician system, and (4) enhance emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services. Methods We will evaluate project implementation in a tripartite prospective and intervention study. First, in medical evaluation, we will assess the influences of various project measures on quality of care using multiple methods. Second, the economic evaluation will mainly focus on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. Third, as part of the work and organizational analysis, we will assess important work- and occupational-related parameters, as well as network and regional indexes. Results We started the project in 2017 and will complete enrollment in 2020. We finished the preanalysis phase in September 2018. Conclusions Overall, implementation of the project will entail realigning emergency medicine in rural areas and enhancing the quality of medical emergency care in the long term. We expect the project to lead to a measurable increase in medical laypersons’ individual motivation to provide resuscitation, to strengthen resuscitation skills, and to result in medical laypersons providing first aid much more frequently. Furthermore, we intend the project to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via mobile phones. Previous projects in urban regions have shown that the tele-emergency physician system can provide a higher availability and quality of emergency call-outs in regular health care. We expect a closer interrelation of emergency practices of statutory health insurance physicians with the rescue service to lead to better coordination of rescue and on-call services. International Registered Report Identifier (IRRID) DERR1-10.2196/14358

Die zweite Saule des Projektes Land|Rettung bestand aus der Einfuhrung einer Smartphone-basierten Ersthelfer-Alarmierung im Landkreis Vorpommern-Greifswald. Sie bietet die Moglichkeit, auch in landlichen Regionen die Versorgung von Patienten mit Herzkreislaufstillstanden zu verbessern. Dieses Kapitel beschreibt, welche Uberlegungen vor und wahrend der Implementierung einer solchen App notig sind und stellt Ergebnisse der Evaluation der Land|Retter-App vor. Im vorherigen Kapitel wurde erlautert, wie entscheidend der fruhzeitige Beginn von Wiederbelebungsmasnahmen bei einem Herzkreislaufstillstand ist. In Kapitel 4 wird gezeigt, welche Auswirkungen die Einfuhrung einer Telenotarzt-Anwendung in einem Landkreis hat. Die Saule 2 des Projektes Land|Rettung, und damit auch dieses Kapitel, stellt eine Brucke zwischen diesen beiden Themen dar und verbindet Wiederbelebungsmasnahmen mit Telemedizin.

Die Notrufnummer 112, unter der der Rettungsdienst zu akuten und lebensbedrohlichen Erkrankungen alarmiert werden kann, ist in der deutschen Bevolkerung gut bekannt. Weniger bekannt hingegen ist der Kassenarztliche Notdienst und die Rufnummer 116117. Dieser Notdienst kann auserhalb der Praxisoffnungszeiten zu Beschwerden alarmiert werden. Rettungsdienst und kassenarztlicher Notdienst sind sich erganzende Systeme, die jedoch aktuell unabhangig voneinander agieren. In diesem Kapitel werden exemplarisch am Landkreis Vorpommern-Greifswald Hurden vorgestellt, die fur eine verbesserte Verzahnung uberwunden werden mussen. Eine bundesweite Studie stellt den aktuellen Kenntnisstand der Bevolkerung auf diesem Gebiet vor. Die derzeitigen politischen Debatten sehen zukunftig eine gemeinsame Disponierung beider Dienste vor. Diese strukturellen Veranderungen stellen Herausforderungen dar, welche im Ausblick diskutiert werden.

Telemedizinische Prozessinnovationen, wie das Konzept des Telenotarzt-Systems, nehmen zunehmend eine zentrale Bedeutung in den Versorgungsstrukturen der prahospitalen Notfallversorgung ein. In diesem Kapitel soll interdisziplinar aufgezeigt werden, welchen Einfluss die Einfuhrung des Telenotarzt-Systems in dem Landkreis Vorpommern-Greifswald auf die bestehenden Prozessablaufe nimmt. Neben der organisatorischen Etablierung des Systems stehen weiterhin die Auswirkungen auf die Qualitat in der Patientenversorgung, die Wirtschaftlichkeit und die Mitarbeiterzufriedenheit der in dem System beteiligten Akteure im Mittelpunkt. Weiterhin wird aufgezeigt, welche strukturellen und finanziellen Erfordernisse perspektivisch bei der langfristigen Implementierung des Telenotarzt-Systems in die Regelversorgung zu beachten sind.

Kap. 6 adressiert die saulenubergreifende Evaluation aus einer arbeits- und organisationswissenschaftlichen Perspektive. Diese sollte vor allem sicherstellen, dass die Einfuhrung der Innovation in der Notfallmedizin dauerhaft funktionsfahig und die dabei gewonnenen Erkenntnisse und Erfahrungen auf andere Regionen ubertragbar sind. In diesem Kapitel werden die vielfaltigen Untersuchungen dieser Evaluation vorgestellt, welche sich vornehmlich an den verschiedenen Ebenen von Arbeit und Organisation orientierten, die von der Umstellung in der Notfallmedizin betroffen sind.

BACKGROUND The German Emergency Medical Services is a two-tiered system with paramedic staffed ambulances as primary response supported by pre-hospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply whilst the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of essence [1], because with each minute passing, the chance of survival with good neurological outcome decreases. OBJECTIVE The project follows four main objectives: 1) Reducing the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (called bystander-CPR), (2) fast, professional first aid in addition to rescue services through alarming trained first aiders via smartphone, (3) faster and higher availability of emergency physicians through introducing the tele-emergency physician (TEP) system, and (4) enhanced emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services. METHODS The implementation of the project is evaluated through a tripartite prospective and intervention study: (1) in medical evaluation, the influences of various project measures on quality of care are assessed using multiple methods. (2) The economic evaluation mainly focuses on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. (3) As part of the scientific work and organizational evaluation important work- and occupational-related parameters but also network and regional indexes are assessed. RESULTS The project was started in 2017 and enrollment will be completed in 2020. The pre-analysis phase recently finished. CONCLUSIONS Overall, the implementation of the project entails the realignment of emergency medicine in rural areas and the enhancement of quality of medical emergency care in the long-term. It is expected to lead to a measurable increase in medical laypersons’ individual motivation to provide resuscitation, to strengthen resuscitation skills as well as much more frequently provided first aid through medical laypersons. Furthermore, the project is intended to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via smartphones. As demonstrated by previous projects in urban regions, the TEP system has already proven a higher availability and quality of emergency call-outs in regular health care. A closer interrelation of emergency practices of statutory health insurance physicians with the rescue service is expected to lead to a better coordination of rescue and on-call services. CLINICALTRIAL Ethikkomission (ethics comission) an der Universität Greifswald BB 111/17 http://www2.medizin.uni-greifswald.de/ethik/