Dyspnea is the subjective sensation of difficult or uncomfortable breathing. It accounts for approximately 10% of emergency department visits and 8% of calls to Emergency Medical Communication Centers. Nearly half of patients presenting with dyspnea require hospital admission, 15% require ventilatory support, and approximately 5% die. Early recognition of signs of respiratory severity is therefore essential to accurately assess clinical urgency, guide diagnostic evaluation, and inform appropriate management decisions.
In France, patients are encouraged to contact an Emergency Medical Communication Centers before presenting to an emergency department. Calls are managed by an emergency physician responsible for medical regulation, who performs a remote clinical assessment and determines the most appropriate level of care. Depending on the clinical evaluation, the physician may provide medical advice, refer the patient to an emergency department, dispatch emergency medical services, or send a physician-staffed mobile intensive care unit for life-threatening emergencies.
The remote assessment of patients presenting with dyspnea is particularly challenging. The inability to directly observe or examine the patient, combined with the caller's difficulty in accurately describing the clinical situation, may impair the recognition of disease severity and result in inappropriate triage decisions, including under-triage and over-triage :
Under-triage, characterized by failure to dispatch appropriate emergency resources or to refer the patient to an emergency department when indicated, may delay treatment and increase the risk of adverse outcomes, including mortality.
Conversely, over-triage, defined as unnecessary referral to primary care or emergency departments or inappropriate dispatch of emergency resources, contributes to emergency department overcrowding, inefficient use of prehospital resources, and increased healthcare costs.
In a previous study, we demonstrated that video-assisted medical triage improved emergency physicians' ability to assess the severity of patients presenting with acute dyspnea. This telemedicine tool enables real-time transmission of a live video stream from the caller's smartphone camera to the emergency physician through a secure digital platform, providing direct visualization of the patient's clinical condition. By enhancing remote clinical assessment, video-assisted triage has the potential to reduce both under-triage and over-triage.
In the present stepped-wedge cluster randomized trial, we hypothesized that incorporating real-time video support into the medical regulation of adult patients contacting an Emergency Medical Communication Centers for acute dyspnea would improve the quality of medical decision-making compared with standard telephone triage alone.
Patients aged 18 or over
Contacting the Emergency Medical Communication Center regarding acute dyspnea, respiratory distress or shortness of breath, as the main reason for the call, regardless of the underlying cause
The patient or a bystander must have a mobile phone equipped with a camera and capable of making video calls
Emergency inclusion authorized by the emergency physician responsible for medical regulation in accordance with the emergency consent procedure applicable at the time of the call
Refusal to pursue the study (patient or relative consent withdrawal).
Patient not benefiting from a social security system.
Free subject, without guardianship nor subordination.
Sequential
Addition of telemedine to standard medical dispatching process
Other interventionPatients included during the intervention phase will undergo video-assisted medical triage. Video-assisted triage will be performed using a secure web-based telemedicine hosted on a certified health data server. The emergency physician responsible for medical regulation will send a secure web link via SMS to the caller's smartphone or, when appropriate, to the smartphone of a relative or bystander. Once the link has been activated, a live video stream captured by the smartphone camera will be securely transmitted in real time to the physician's workstation at the Emergency Medical Communication Center, enabling direct visualization of the patient's clinical condition during the remote assessment.
Proportion of inappropriate medical dispatch decisions (under-triage or over-triage)
Under-triage is defined as the assignment of a level of response that is insufficient for the patient's actual clinical needs. Under-triage is defined: 1) either as a patient receiving a medical advice alone at the initial call and within 24 hours; referred to an ED after a second call to EMCC or non-scheduled hospitalization or death or secondary EMS unit dispatched; 2) either as a patient initially dispatched to an ED (not with an EMS) and within 3 hours; required ventilatory support or cardiac arrest or death or secondary EMS unit dispatched. Over-triage is defined as the assignment of a level of response that exceeds the patient's actual clinical needs. Over-triage is defined as an EMS unit being dispatched or a patient being referred to an ED after the initial call to an EMCC and, at the end of emergency management, no additional examination, no specific treatment , no hospitalization being required within 24 hours following the call to the EMCC.
Proportion of patients in under-triage situation
Definition of under-triage is given in the primary outcome.
Proportion of patients in over-triage situation
Definition of over-triage is given in the primary outcome
Proportion of patients requiring advanced respiratory support (defined as any oxygenation or ventilatory support beyond conventional oxygen therapy)
Proportion of patients admitted to an intensive care unit
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