Improved technical performance of a multifunctional prehospital telemedicine system between the research phase and the routine use phase

Abstract

Introduction

Telemedical concepts in emergency medical services (EMS) lead to improved process times and patient outcomes, but their technical performance has thus far been insufficient; nevertheless, the concept was transferred into EMS routine care in Aachen, Germany. This study evaluated the system’s technical performance and compared it to a precursor system.

Methods

The telemedicine system was implemented on seven ambulances and a teleconsultation centre staffed with experienced EMS physicians was established in April 2014. Telemedical applications included mobile vital data, 12-lead, picture transmission and video streaming from inside the ambulances. The tele-EMS physician filled in a questionnaire regarding the technical performance of the applications, background noise and assessed clinical values of the transmitted pictures and videos after each mission between 15 May 2014–15 October 2014.

Results

Teleconsultation was established during 539 emergency cases. In 83% of the cases (n = 447), only the paramedics and the tele-EMS physician were involved. Transmission success rates ranged from 98% (audio connection) to 93% (12-lead electrocardiogram (ECG) transmission). All functionalities, except video transmission, were significantly better than the pilot project (p < 0.05). Severe background noise was detected to a lesser extent (p = 0.0004) and the clinical value of the pictures and videos were considered significantly more valuable.

Discussion

The multifunctional system is now sufficient for routine use and is the most reliable mobile emergency telemedicine system compared to other published projects. Dropouts were due to user errors and network coverage problems. These findings enable widespread use of this system in the future, reducing the critical time intervals until medical therapy is started.

Keywords

Telemedicine ambulance video transmission teleconsultation emergency medical service

Introduction

Telemedical procedures and applications have become increasingly important in emergency and acute care settings; however, these applications are often restricted to research and pilot projects and broad implementation into routine care is lacking.¹ In acute stroke, video transmission from the ambulance is feasible and sufficient for remote support in stroke diagnosis.^2,3 Stroke-specific data transfer to the clinical stroke centre was significantly improved by using video transmission and telemedical expert help, including a software-based stroke checklist.³ Although only a few projects demonstrated video transmission from the ambulance, the American Heart Association and American Stroke Association recommended the use of video transmission in suspected stroke to improve prehospital triage.^4,5 The use of a tablet computer-based stroke score and consecutive automated pre-information for the admitting stroke centre reduced the in-hospital time interval from patient arrival to cerebral imaging and, if applicable, intravenous thrombolysis.⁶ In acute myocardial infarction, the in-hospital time intervals were significantly shortened when using 12-lead electrocardiogram (ECG) transmission and cardiologist consultation.^7–9 Finally, this led to improved patient outcomes and should therefore implemented into routine care in all structured emergency medical services (EMS).¹⁰

Two research projects with a multifunctional telemedicine system for EMS were conducted in Germany. During the first research project, the technical and organisational feasibility of the telemedicine system were evaluated in real patient care. At this time, the technical performance was not completely sufficient to transfer this concept into routine care.¹¹ In the second research project, the system was further developed and teleconsultation, with the use of real-time vital data transmission and also video transmission from the ambulance, was used by paramedics in five different EMS districts in a multicentre study.^12,13 Delegation of medications to paramedics based on teleconsultation was safe and practicable. The technical performance improved in comparison to the first project but was only evaluated in simulated scenarios.^11,14 The final reports of the previous two research projects were discussed with the insurance companies. Due to the novelty of the concept and the incomplete evidence regarding quality of care, the first reimbursement for routine care was limited to two consecutive years (April 2014–March 2016). Despite some lacking evidence the insurance companies identified a potential for improved patient care on the one hand and optimised efficiency in EMS on the other hand. Based on these first results, the concept was transferred to insurance-funded routine care in a pilot region in Germany. The aim of this study was to evaluate, research and compare the technical performance of the significantly more developed telemedicine system, and compare this to the performance of the precursor system.

Methods

Against this background, a multifunctional mobile prehospital telemedicine system was implemented into EMS routine care in Aachen, Germany from April 2014–October 2014. The city of Aachen is an urban area with a population density of 1513 citizens/km² (mean population density in Germany: 228 citizens/km²). Specifically, telemedically-equipped ambulances could consult a tele-EMS physician who was located in a teleconsultation centre (Figure 1). Until June 2014, the teleconsultation centre was run from 07:30–20:15 daily and four ambulances were connected. Since July 2014, the centre has been run on a 24/7 basis and three more paramedic-staffed ambulances were equipped and connected stepwise until September 2014. All physicians in the teleconsultation centre had at least four years of clinical experience in anaesthesia and critical care, were certified in prehospital emergency medicine with at least 500 missions experience, and were current Advanced Life Support and Pre-Hospital Trauma Life Support providers.

Figure 1.

Components and functionalities of the telemedicine system. GPS: global positioning system; MU: mobile communication unit; SOP: standard operating procedure.

Technical system architecture

The two main components of the telemedicine system were the teleconsultation centre and the telemedically-equipped ambulances (Figure 1). An in-car communication unit and a mobile communication unit (MU) were installed (P3 telehealthcare, Aachen, Germany) into each ambulance. All data transmission was encrypted and automatically parallelised via different mobile network providers, if required due to non-optimal network coverage. The MU enables audio and parallelised data transmission via up to three different mobile networks of the second and third generation (GSM, EDGE, UMTS, HSUPA). The in-car unit provides transmission through up to five mobile networks this way. If the MU runs inside the ambulance, all data traffic is redirected via a local wireless network (WLAN) from the MU to the in-car unit to enhance transmission quality and to prevent local interference from other devices. The in-car unit is connected to roof antennae on top of the ambulance. A monitor-defibrillator unit is attached to the MU (Corpuls;³ GS Elektromedizinische Geräte G Stemple, Kaufering, Germany). Furthermore, two Bluetooth headsets (Voyager Pro or Voyager Legend; Plantronics, Santa Cruz, California, USA) for voice communication and a smartphone (HTC Desire 500, HTC Sensation XE, High Tech Computer Corporation, Taoyuan, Taiwan) are connected to the MU. The smartphone forwards still pictures via Bluetooth to the MU for encrypted transmission. Overall, the multifunctional telemedicine system enables the following applications:

Audio communication between paramedics and the tele-EMS physician

Real-time vital data transmission (numerical values and curves)

12-lead ECG transmission

Still picture transmission via the Bluetooth connection of the MU and a smartphone

Real-time video streaming from a 360° camera embedded into the ceiling of each ambulance (Sony SNC-RZ 50P (1280 × 720 pixels, 30 images/s) or Sony SNC-EP 550 (640 × 480 pixels, 25 images/s), Sony Electronics Inc., San Jose, California, USA)

Printing of a teleconsultation report inside the ambulance (PJ-623; Brother International GmbH, Bad Vilbel, Germany)

Position of the ambulance using GPS technology (P3 telehealthcare, Aachen, Germany).

The technical evolution between the pilot research project and the analysed routine care phase is summarised in Table 1. In the teleconsultation centre, the transmitted data were displayed on a computer workstation with four standard monitors, using software that was specifically developed for this purpose (Telemedical documentation; P3 telehealthcare, Aachen, Germany). To display the vital data and 12-lead ECGs on the workstation, software from the manufacturer of the monitor-defibrillator unit was embedded into the telemedical documentation software (corpuls.web; GS Elektromedizinische Geräte G. Stemple, Kaufering, Germany). This software mirrored the screen of the monitor-defibrillator unit and ensured that the data were correctly displayed. The software was licensed for this purpose and remote diagnosis was allowed according to German regulations.

Table 1.

Technical evolution between the research project 2009/2010 and the routine care phase 2014.

Component	Research project	Routine care	Evolution/changes
Data transmission	Solely one unit, embedded into a backpack, total weight 15 kg, connection to the roof antennas via a cable-based connector was necessary. No redundant connection.	Small mobile transmission unit, total weight of 2.2 kg; inside the ambulance all data transfer is automatically routed via Wi-Fi to an in-car computer. Redundant connection via in-car computer.	Weight reduction of 85%. Redundant connections. System made more practicable.
Monitor-defibrillator	Vital data transmission only possible via a small additional patient monitor; defibrillator unit had to be carried additionally and was not connected to the system.	Standard monitor-defibrillator unit is connected to the mobile data transmission unit. Transmission of defibrillation and pacing settings.	Weight reduction. All-in-one solution. System made more practicable. More telemedical supervision possible.
Still picture transmission	Additional digital camera that has to be connected via WiFi to the data transmission unit.	One smartphone as backup-solution for the voice communication and automated transmission of all taken pictures.	All-in-one solution compared to mobile phone and digital camera.
Teleconsultation centre	Software self developed, not context sensitive, self developed software for displaying of transmitted vital data, no redundant connections.	Professional software that is certified for this purpose, context sensitivity for all standard emergency situations, redundant connections.	Context sensitivity with checklists for all common emergencies. Guideline-based therapy recommendations integrated. Redundant connections.
Technical support	By the research group.	24/7 professional technical support.	Shorter response times in technical problems.

In addition to displaying all the transmitted data, this context-sensitive software guides the tele-EMS physician through the consultation process and communication. For all standard emergency situations, algorithms and checklists based on international and national guidelines are provided to enable uniform guideline-adherent emergency care.

Workflow – organisational setup

In Germany, a two-tiered EMS system is run with paramedics and EMS physicians. Paramedics have a two-year training programme and restricted medical competences. Only in life-threatening situations are paramedics allowed to administer certain medications prior to the arrival of an EMS physician. We implemented a third tier – the teleconsultation system – between paramedic care alone and on-scene care by an EMS physician. Prior to the use of the teleconsultation system, all paramedics attended a five-hour training session on the teleconsultation system and predefined standard operating procedures (SOPs) by the EMS medical director. In regular emergency missions, the paramedics decided in each particular case if telemedical support was necessary (e.g. for delegation of opioids for analgesia, co-interpretation of 12-lead ECGs, co-evaluation of stroke symptoms via video transmission) based on the SOPs. For telemedical support of inter-hospital transfers, a checklist-guided dialogue between the tele-EMS physician and the discharging hospital physician was conducted. Based on the obtained information and a SOP, the transport strategy was determined.

Study design and data sources

After each teleconsultation from 15 May 2014–15 October 2014, the tele-EMS physician filled in a standardised, paper-based questionnaire regarding the technical performance from the user's perspective. The transmission quality for each application was assessed using a four-stage scale (Table 2). The possible reasons for background noise and all detected problems were requested to be documented on this sheet. Furthermore, the tele-EMS physicians evaluated the clinical value of the transmitted still pictures and the conducted video-streaming from their perspective, with respect to the individual mission. Scales and question types were used the same way as in our first research project to make the findings comparable.¹¹

Table 2.

Transmission quality of telemedical applications.

Application	Research project 2009/2010 vs routine use in 2014	No malfunctions	Some malfunctions, quality not affected	Malfunctions, quality reduced	Malfunctions, transmission impossible	p-value
Voice	Research project (n = 143)	66 (46%)	33 (23%)	28 (20%)	16 (11%)	p < 0.0001
Voice	Routine use (n = 493)	365 (74%)	93 (19%)	23 (5%)	12 (2%)	p < 0.0001
Vital data	Research project (n = 153)	46 (30%)	37 (24%)	40 (26%)	30 (20%)	p < 0.0001
Vital data	Routine use (n = 444)	300 (68%)	101 (23%)	22 (5%)	21 (4%)	p < 0.0001
12-lead-ECG	Research project (n = 77)	49 (64%)	4 (5%)	7 (9%)	17 (22%)	p = 0.0011
12-lead-ECG	Routine use (n = 223)	181 (81%)	15 (7%)	11 (5%)	16 (7%)	p = 0.0011
Pictures	Research project (n = 77)	56 (73%)	3 (4%)	9 (12%)	9 (11%)	p = 0.0188
Pictures	Routine use (n = 267)	241 (90%)	10 (4%)	6 (2%)	10 (4%)	p = 0.0188
Video	Research project (n = 36)	20 (56%)	10 (28%)	4 (11%)	2 (5%)	p = 0.294
Video	Routine use (n = 298)	266 (89%)	21 (7%)	3 (1%)	8 (3%)	p = 0.294

A teleconsultation report was printed inside the ambulance and inside the teleconsultation centre after each mission. This report contained the diagnosis by the tele-EMS physician, medical history, conducted procedures, administered medications, and the seven-stage National Advisory Committee for Aeronautics (NACA) severity score (Table 3). Adverse events and other complications were reported on this form as well, if applicable.

Table 3.

Medical severity in comparison between the research project and the routine care phase.

Medical severity	Research project 2009/2010, n = 157		Routine use 2014, n = 539
Medical severity	n	Fraction	n	Fraction
NACA I (marginal impairment)	14	11.4%	4	0.8%
NACA II (outpatient care)	18	14.6	41	7.8%
NACA III (admission to hospital necessary)	47	38.2%	321	61.3%
NACA IV (potential vital danger)	27	22.0%	107	20.4%
NACA V (acute vital danger)	14	11.4%	49	9.4%
NACA VI (successful cardiopulmonary resuscitation)	1	0.8%	1	0.2%
NACA VII (death)	2	1.6%	1	0.2%

NACA: National Advisory Committee for Aeronautics.

The questionnaire data and the mission characteristics (NACA severity score, diagnoses, mission category, delegation of medications) from the teleconsultation reports were extracted.

All data were prospectively collected for quality management purposes and analysed retrospectively for this study. During extraction from the original documentation to a spreadsheet programme (Microsoft Excel, Microsoft Corporation, Redmond, Washington, USA), all data were anonymised. For comparison with historical data from the research project, the original data of n = 157 telemedically supported missions – described previously in this journal – were also imported, anonymised, and used for statistical analysis.¹¹

Ethics and data privacy

Data transmission was only started after the patient (if alert) verbally consented to it. Due to the fact that only routine data were used and patient data were anonymised prior to statistical analysis, the local ethics committee waived a formal consult of the ethics committee (EK109/15, University Hospital RWTH Aachen).

Statistical methods

We used a Mantel-Haenszel chi-square test to compare the technical performance of the telemedical applications. Fisher's exact test was used to compare 0/1 variables. Because the study was designed to be exploratory, p-values < 0.05 were considered significant. All statistical analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, North Carolina, USA).

Results

Overall, 539 emergency missions, 438 regular emergency and 101 inter-hospital transfer missions, were telemedically supported during the five-month study phase.

Mission characteristics

In 447 missions (82.9%), the paramedics conducted patient care with guidance by the tele-EMS physician so that an on-scene EMS physician was not necessary. In the remaining 92 cases, an on-scene EMS physician was involved in the course of the mission due to the medical severity. There was no case in which the telemedical service was unavailable due to concurrent cases or technical reasons. During 229 (52.3%) of the 438 regular emergency missions, the tele-EMS physician delegated medications to the paramedics based on guideline-adherent algorithms and checklists displayed in the software; in n = 61 missions (26.3% of the missions with delegated medications), the tele-EMS physician ordered the paramedics to administer opioids. Table 3 displays the severity of the missions during the study and historical phases. The mean severity was significantly lower in the historical control period than in the study phase (mean NACA score 3.06 vs 3.30, p = 0.009). The prehospital diagnoses of both phases are contrasted in Table 4.

Table 4.

Diagnoses of the emergency missions.

Diagnoses	Research project 2009/2010		Routine care 2014
Diagnoses	n	Fraction	n	Fraction
Acute coronary syndrome	14	8.9%	64	11.9%
Hypertensive emergency	6	3.8%	56	10.4%
Other cardiovascular emergency	35	22.3%	82	15.2%
Acute stroke	11	7.0%	33	6.1%
Other neurological emergencies	6	3.8%	33	6.1%
Respiratory emergency	13	8.3%	23	4.3%
Gastrointestinal emergency	5	3.2%	45	8.3%
Trauma	27	17.2%	90	16.7%
Other emergencies	40	25.5%	113	21.0%
Total	157		539

Technical performance

The technical performance of the single applications is summarised in Table 2. The successful transmission rates ranged from 93% (12-lead ECG) to 98% (audio connection). The reliability of the functionalities improved significantly, compared to the first project. The performance of the video streaming also improved but without statistical significance. Complete drop-outs of the whole system were detected in three of 539 missions (0.6%) compared to five of 157 (3.2%) in the historical data. In this context ‘complete drop-out’ meant that teleconsultation was not possible due to technical reasons and that the intention to use teleconsultation was therefore abandoned.

The quality of the transmitted still pictures and videos were high, with significantly improved still picture quality compared to the historical phase (Table 5). Also, the clinical value of both the video and still pictures was significantly higher than in the pilot project (Table 5). The incidence and reasons for background noise and disturbances during audio communication are also displayed in Table 5. The prevalence of severe background noise was low, improved significantly over time, and the ‘EMS team’ was no longer a main reason for background noise, compared to the historical data.

Table 5.

Quality and clinical value of still pictures and videos as well as background noises during audio communication.

	Research project 2009/2010		Routine use 2014
Rating	n	Fraction	n	Fraction	p-value
Quality of transmitted still picture
Excellent	15	23.4%	67	27.0%	0.0011
Good	32	50.0%	164	66.1%
Moderate	11	17.2%	14	5.6%
Rather poor	6	9.4%	2	0.8%
Unusable	0	0%	1	0.4%
Clinical value of transmitted still pictures
Very helpful	15	23.4%	129	52.0%	<0.0001
Helpful	30	46.9%	104	41.9%
Rather helpful	5	7.8%	10	4.0%
Rather not helpful	8	12.5%	3	1.2%
Not helpful at all	6	9.4%	2	0.8%
Quality of video transmission
Excellent	12	33.3%	106	36.9%	0.2893
Good	20	55.6%	158	55.1%
Moderate	2	5.6%	22	7.7%
Rather poor	2	5.6%	1	0.3%
Unusable	0	0%	0
Clinical value of video transmission
Very helpful	10	27.8%	106	37.1%	<0.0001
Helpful	8	22.2%	143	50.0%
Rather helpful	4	11.1%	32	11.2%
Rather not helpful	11	30.6%	5	1.7%
Not helpful at all	3	8.3%	0	0%
Severity of background noises
None	45	30.4%	238	49.2%	<0.0001
Little	69	46.6%	202	41.7%	0.2982
Some	22	14.9%	36	7.4%	0.0089
Extensive	12	8.1%	8	1.7%	0.0004
Reasons for background noises
Team	25	17.2%	9	2.5%	<0.0001
Patient	17	11.7%	27	7.6%	0.1637
Ambient noise	62	42.8%	139	39.2%	0.4827
Technical noise	41	28.3%	131	36.9%	0.0776
Transport	N/A	N/A	49	13.8%	N/A

Discussion

Our study showed that the technical and organisational concept of multifunctional teleconsultation was successfully transferred from a research project to routine patient care use. While an on-scene EMS physician established the telemedical connection in the previous research project, the connection was now established between the on-scene paramedics and a tele-EMS physician to enable telemedical support on every ambulance. The system was mainly operated during regular emergency missions and to a lesser extent during inter-hospital transfers. Complete drop-outs of the whole system were very rare and the performance of the single telemedical applications improved significantly. While the precursor system was not sufficient for routine EMS use, the sufficiency of the system for this purpose could now be demonstrated on a much larger case series. Video transmission was the only application that was already satisfactory during the research project (2009/2010) and therefore we detected no statistically significant improvement with this application. At this point, it must be mentioned that video streaming was solely performed from inside the ambulance using the in-car connection with roof antennas. This connection is probably more stable and reliable than the ultra-mobile connection with the MU, especially if performed inside buildings. Overall, the reasons for the detected malfunctions ranged from user errors to network coverage problems. With our data, the specific reasons for the malfunctions were not detectable in detail, because user errors could not be detected with certainty. Although the system was implemented into routine care, the usage was new and challenging for the paramedics due to the new tasks that were previously performed by EMS physicians (e.g. opioid-based analgesia); therefore, some operating errors by the users are explainable. The five-hour training of the paramedics may need to be extended and adjusted to ensure accurate use. Although a multi-channel connection technology was used, we had no influence over the coverage with second- and third-generation mobile networks. Some of the malfunctions are probably caused by network coverage gaps. The significantly reduced occurrence of background noise also shows that the system is now suitable for routine use. Compared to the research project in 2009/2010, the headset technology probably improved which explains why the EMS team was not a main factor for background noise any more.¹¹ The assessed clinical value of the transmitted pictures and videos was higher because the tele-EMS physician had not only an advisory function for an on-scene physician, but also was in charge of whole patient care with only paramedics on-scene in 83% of the cases. Therefore, information on still pictures, like medication lists, medical reports and video of patient movements or skin colour, were valuable in making preliminary diagnoses and to rule out contraindications for certain medications. In addition, the emergency severity in this study was significantly higher than in the research project, which had an EMS physician on-scene in every case. During the research project teleconsultation was mandatory to gain technical experience. Since the system was implemented into routine care the paramedics on-scene decide to initiate teleconsultation solely based on the medical severity and the mandatory medical procedures. Probably a higher medical severity during the routine care phase can be explained this way.

Compared to a research project in Brussels, Belgium, we detected higher success rates in vital data transmission (93–98% vs 64–84.8%). Furthermore, our system allows the integration of all the vital data of the standard monitor-defibrillator unit, which was not enabled with the Prehospital Stroke Study at the University Hospital Brussels System in Brussels.¹⁵ However, our system only allowed unidirectional video transmission from the ambulance to the teleconsultation centre. Systems that enable a bidirectional videoconference between the EMS team – and also the patient – and the teleconsultant are possibly in advance regarding prehospital diagnosis and patient satisfaction. Scientific reports that evaluate this theory are limited to in-hospital use; for example, in the Western Australian Country Health Service.¹⁶ Compared to Liman et al. and Kwak et al., we also detected much more reliable video transmission (97% vs 40% and 84% respectively).^17,18 Video transmission for enhancing remote stroke diagnosis was already evaluated in 2004 with standardised simulated patients and led to a recommendation from the American Heart Association, but with real patients and the operation of a multifunctional mobile system we present the largest series so far.^2,4,5 The performance of vital data and still picture transmission were completely practicable, but the success rate of the 12-lead ECG transmission must be further improved. Regarding this application, user errors are plausible. If the MU was already running when the monitor-defibrillator unit was turned on, the connection between the two devices occurred automatically; if the monitor-defibrillator unit was already running and the MU had to be started manually (e.g. because of changing the accumulator), the connection had to be established manually which required in-depth user knowledge of both units. Some of the failed transmissions can be explained this way. Nevertheless, failed 12-lead ECG transmissions have to be judged extremely critically because strong evidence exists for this application regarding the improvement of process times and patient outcomes.^8,10,19 The future design of telemedicine systems should prevent such user errors by using a simple technology setup and a more user-friendly interface.

No fourth-generation mobile network connection (LTE) was included with our system, but even with third- and second-generation networks, sufficient data transfer was detected. If LTE is implemented in the future, the success rates will probably improve even further. Before using LTE, the performance of the 4G network should be assessed at the location of the proposed service.²⁰

Limitations

First of all, it must be mentioned that the compared groups were of different sizes and in different organisational settings. Nevertheless, this was the only way to analyse the technical development over time. We were not able to present any technological data, like bandwidth and transmission rates, but the evaluation of the technical performance by the receiving user is the most critical analysis, from our perspective. This study was not designed to present patient outcome data. Therefore, it is debatable if the described telemedical workflow has any impact on patient care and outcome; however, in precursor projects, we were able to show that, overall, teleconsultation in EMS is safe, improves stroke-specific data transfer and enables early comprehensive intravenous therapy by on-scene paramedics.^3,12,13 Analgesia carried out by paramedics this way is also sufficient, compared to analgesia carried out by on-scene EMS physicians, and leads to significantly improved analgesia-related documentation quality.²¹

Conclusion

Overall, the proof of the sufficiency of this technology enables the future widespread use of multifunctional teleconsultation in underserved areas to reduce the time-span until medical therapy is initiated. We are not able to answer whether the technical performance is also sufficient in rural areas with possibly lower network coverage, but the multichannel technology enables higher reliability than single-network systems.^15,17 Further studies must research the impact of the multichannel technology on patient outcomes and emergency medical care-related quality parameters.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MF, SB, FH, MT, and SKB declare no conflicts of interest. JCB and RR are shareholders and MC is a shareholder and employee of the Docs-In-Clouds company Aachen, Germany.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Improved technical performance of a multifunctional prehospital telemedicine system between the research phase and the routine use phase – an observational study

Abstract

Introduction

Methods

Results

Discussion

Keywords

Introduction

Methods

Technical system architecture

Workflow – organisational setup

Study design and data sources

Ethics and data privacy

Statistical methods

Results

Mission characteristics

Technical performance

Discussion

Limitations

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References