Are there any differences in prehospital ACS care within one city? Comparison of prehospital care provided by emergency physicians from two tertiary care hospitals. Further evaluations of the “MONAH-1” study

Are there any differences in prehospital ACS care within one city? Comparison of prehospital care provided by emergency physicians from two tertiary care hospitals. Further evaluations of the “MONAH-1” study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Are there any differences in prehospital ACS care within one city? Comparison of prehospital care provided by emergency physicians from two tertiary care hospitals. Further evaluations of the “MONAH-1” study Tobias Hofmann, Peter Baumann, Martin Sauer, Thomas Schilling, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9087668/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Acute coronary syndrome (ACS) is a time-critical medical emergency in which early guideline-based prehospital diagnosis and treatment are crucial for the further course of treatment. The aim of this study was to compare the quality of prehospital care provided by emergency physicians at two maximum care hospitals in Magdeburg. Methods As part of the retrospective, bicentric observational study MONAH-1, all prehospital physician missions with typical ACS diagnoses in Magdeburg between 2014 and 2018 were analysed. Using defined quality indicators in accordance with ESC guidelines (including 12-lead ECG, administration of acetylsalicylic acid (ASA), heparin, morphine, oxygen and nitro-glycerine), a comparison was made between emergency physicians at the University Medical Centre (MD1) and Magdeburg Hospital (MD2). The statistical analysis included univariate and multivariate logistic regression analyses adjusted for age and gender. Results A total of 1,438 emergency physician interventions were evaluated (MD1: n = 661; MD2: n = 777). Emergency physicians at MD1 performed 12-lead ECGs significantly more often (76.9% vs. 43.5%; aOR 4.24 [95% CI 3.36–5.35]), administered ASA more often (91.4% vs. 70.9%; aOR 4.38 [3.19–6.00]) and heparin (92.6% vs. 68.0%; aOR 5.86 [4.21–8.16]) more frequently, and administered morphine for pain intensity VAS ≥ 4 (70.6% vs. 54.5%; aOR 2.67 [2.04–3.50]; p < 0.001 in each case). No significant differences were found for the indication-appropriate administration of nitro-glycerine and oxygen. The prehospital dwell time was longer in MD1 (median 34 vs. 29 minutes; p < 0.001). Conclusion Prehospital care for ACS patients differed between the two emergency medical service locations. Emergency physicians at MD1 implemented guideline-recommended diagnostic and therapeutic measures more frequently, possibly facilitated by a longer prehospital dwell time and location-specific organisational structures. The results underscore the influence of organisational conditions on the quality of prehospital care and provide starting points for future quality assurance measures. prehospital care MONAH-1 study ACS emergency physicians Introduction Acute coronary syndrome (ACS) is one of the most time-critical medical emergencies, in which early diagnosis and guideline-based therapy are crucial for the morbidity and mortality of those affected. Even in the prehospital setting, the emergency physician can take essential measures, including structured clinical assessment, recording and interpretation of a 12-lead electrocardiogram, and early initiation of evidence-based drug therapy. Prehospital care quality thus plays a key role in the overall treatment pathway of patients with ACS. [ 1 , 2 ] In Magdeburg, the capital of Saxony-Anhalt, three EMS physician bases are staffed 24/7 to ensure emergency care for the population. Two hospitals provide the emergency physician staffing. During the period under review, one base was staffed by Magdeburg University Hospital (MD1) and two EMS physician bases by Magdeburg Hospital (MD2). Against this background, the standardised clinical picture of acute coronary syndrome provides a suitable basis for the objective assessment of prehospital care quality. The objective of this study was to analyse and compare the quality of prehospital care provided by the emergency physicians at the two hospitals in Magdeburg. The study is based on prehospital care data collected from ACS patients as part of the MONAH-1 study. The comparison aims to provide information on the extent to which guideline-compliant measures and care standards are implemented in the prehospital setting and whether there are any relevant differences between the participating providers. Patients and methods Study design and setting: This manuscript reports a prespecified Magdeburg subgroup analysis of MONAH-1, a retrospective bicentric observational study on prehospital emergency physician management of suspected acute coronary syndrome (ACS). The overall MONAH-1 design, case-identification strategy, and protocol-based extraction approach have been described previously in the published region-based comparison by Hofmann et al. [ 17 ]. In the present analysis, only cases managed at the three EMS physician bases in Magdeburg were evaluated. Guideline basis and quality indicators: Guideline adherence was assessed against the European Society of Cardiology recommendations applicable during the study period (2014–2018) for ST-elevation myocardial infarction and non-ST-elevation ACS [ 3 – 6 ]. From these documents, predefined process indicators were derived for statistical evaluation: acquisition of a 12-lead ECG; administration of acetylsalicylic acid (ASA) and heparin; morphine in patients with relevant pain; oxygen in hypoxaemia; and nitro-glycerine when clinically indicated. Drug selection, indications, and dosing were interpreted according to the contemporaneous guideline documents [ 2 – 6 ]. Case identification: All consecutive prehospital emergency physician missions in Magdeburg between 2014 and 2018 were screened. Cases were included when the protocol documented ACS, STEMI, NSTEMI, unstable angina, myocardial infarction, or acute myocardial infarction. Missions performed by the rescue helicopter Christoph 36 were excluded because these deployments do not reflect routine ground-based emergency physician coverage and the corresponding records were not available for evaluation for data-protection reasons. Setting: During the study period, one Magdeburg EMS physician base was staffed by Magdeburg University Hospital (MD1), whereas two bases were staffed by Magdeburg Municipal Hospital (MD2). Thus, the comparison reflects two provider structures operating within the same urban emergency medical service system. Data acquisition and handling of missing data: Emergency physician protocols from the study period were reviewed in paper or electronic form, depending on the respective base and year of documentation. Both structured check boxes and free-text entries were used to identify diagnoses and prehospital measures. Tactical and demographic variables were analysed only when documented. For treatment-related variables, absence of documentation was classified as "not documented"/not performed for the purpose of process evaluation. For example, a 12-lead ECG was counted only when ECG acquisition or corresponding findings were explicitly recorded in the structured fields or free text. This rule was defined a priori and is consistent with the medico-legal principle that undocumented measures cannot be assumed to have been performed [ 7 ]. Statistical analysis Data were entered into Microsoft Excel and analysed with IBM SPSS Statistics version 29. Categorical variables are reported as absolute and relative frequencies and were compared using chi-square tests or Fisher's exact tests as appropriate. Continuous variables are presented as medians with interquartile ranges and were compared using the Mann-Whitney U test. To examine whether the EMS physician location was independently associated with selected prehospital measures, multivariable logistic regression models were calculated with adjustment for age and sex. Results are reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All statistical tests were two-sided, and p < 0.05 was considered statistically significant. Results A total of 1,438 emergency physician protocols were used for statistical analysis in this article. Of these, 661 patients were treated by emergency physicians at the University Hospital (MD1) and 777 patients were treated by emergency physicians at Magdeburg Hospital (MD2). Table 1 and Table 2 show the patient characteristics (gender distribution, age) and emergency physician characteristics (specialisation and qualifications of the emergency physicians deployed). Table 1 Patient characteristics Variable MD1 (n = 661) MD2 (n = 777) p value Age, years (min–max) 15–99 24–99 0.334 Gender, n (%) 0.004 Male 375 (56.7%) 483 (62.8%) Female Unknown 286 (43.3%) 286 (37.2%) 8 (1,0%) Continuous variables were compared using the Mann–Whitney U test. Categorical variables were compared using the chi-square test. A two-sided p value < 0.05 was considered statistically significant. Table 2 Emergency physician characteristics Variable MD1 (n = 661) MD2 (n = 777) p value Speciality, n (%) 0.001 GM 0 2 (0.3%) AN 661 (100.0%) 565 (72.7%) SU 0 (0.0%) 128 (16.5%) IM 0 (0.0%) 68 (8.8%) UK 0 (0.0%) 14 (1.8%) Qualification, n (%) 0.001 R 369 (55.8%) 347 (44.7%) S 292 (44.2%) 416 (53.5%) UK 0 (0.0%) 14 (1.8%) Categorical variables were compared using the chi-square test. A two-sided p value < 0.05 was considered significant. GM: general medicine; AN: anaesthesia; SU: surgery; IM: internal medicine; UK: unknown; R: resident; S: specialist Further analyses revealed differences in prehospital treatment with regard to therapeutic and diagnostic measures between the emergency physicians at the hospitals under review. The subgroup analysis showed that emergency physicians at MD1 performed 12-lead ECGs more often than emergency physicians at MD2 (76.9% vs. 43.5%; OR 4.31 [95% CI 3.43–5.43]; p < 0.001). The administration of ASA (91.4% vs. 70.9%; OR 4.35 [3.18–5.94]; p < 0.001) and heparin (92.6% vs. 68.0%; OR 5.89 [4.24–8.17]; p < 0.001) was also more common among emergency physicians at MD1. In patients with pain intensity of VAS ≥ 4, morphine was administered by emergency physicians at MD1 in 70.6% of cases, compared with 54.5% by emergency physicians at MD2 (OR 2.01 [1.33–3.05]; p < 0.001). In contrast, there were no differences between the emergency physicians at the two hospitals in the indication-appropriate administration of nitro-glycerine (50.6% vs. 54.8%; OR 0.85 [0.68–1.05]; p = 0.136) and or oxygen (72.7% vs. 78.5%; OR 0.73 [0.33–1.63]; p = 0.445). The results are given in Table 3 . Table 3 Measures taken (subgroup analysis) in MD1 and MD2. Variable MD1 MD2 OR (95% CI) p-value 12-lead ECG 508/661 (76.9%) 338/777 (43.5%) 4.31 (3.43–5.43) < 0.001 Morphine administration (only VAS ≥ 4) 279/395 (70.6%) 67/123 (54.5%) 2.01 (1.33–3.05) < 0.001 Nitro-glycerine administration when indicated 313/618 (50.6%) 386/705 (54.8%) 0.85 (0.68–1.05) 0.136 ASA administration 604/661 (91.4%) 551/777 (70.9%) 4.35 (3.18–5.94) < 0.001 Heparin administration 612/661 (92.6%) 528/777 (68.0%) 5.89 (4.24–8.17) < 0.001 Oxygen administration when indicated 48/66 (72.7%) 51/65 (78.5%) 0.73 (0.33–1.63) 0.445 Notes: Values as n/N (%). Odds ratio (OR) for MD1 compared to MD2. p-values from chi-square test; for small expected frequencies, Fisher's exact test. 95% confidence intervals of OR according to Woolf; for zero cells, Haldane-Anscombe correction The multivariate adjusted analysis (adjustment for age and gender) confirmed these results. Emergency physicians at the MD1 clinic continued to perform 12-lead ECGs significantly more often (aOR 4.24 [3.36–5.35]), and to administer ASA (aOR 4.38 [3.19–6.00]), heparin (aOR 5.86 [4.21–8.16]) and morphine for appropriate indications (aOR 2.67 [2.04–3.50]; p < 0.001 in each case) significantly more often. There were no differences even after adjustment for O₂ administration in cases of hypoxaemia (aOR 0.76 [0.33–1.74]; p = 0.516) and nitroglycerine administration in cases of elevated blood pressure (aOR 0.84 [0.67–1.04]; p = 0.110). These results are shown in Table 4. Table 4: Multivariate analysis MD1 vs. MD2 – prehospital treatment (adjusted for age and gender) Measure N (in model) aOR (95% CI) p-value 12-lead ECG 1415 4.24 (3.36–5.35) <0.001 ASA administration 1415 4.38 (3.19–6.00) <0.001 Heparin administration 1415 5.86 (4.21–8.16) <0.001 Morphine administration when indicated (pain documented) 922 2.67 (2.04–3.50) <0.001 O₂ administration when indicated 128 0.76 (0.33–1.74) 0.51 Nitro-glycerine administration when indicated 1304 0.84 (0.67–1.04) 0.11 Abbreviations: aOR = adjusted odds ratio; CI = confidence interval To explore a possible explanation for the differences in prehospital treatment between the emergency physicians at clinics MD1 and MD2, the PHVZ (prehospital dwell time) was analysed. This was defined as the time from arrival at the patient to handover at the hospital. It differed significantly between the two locations. Emergency physicians at hospital MD1 had a longer PHVZ than emergency physicians at hospital MD2 (median 34 [IQR 29–39] vs. 29 [23–34] minutes; p < 0.001). Summary of results: A total of 1,438 emergency physician interventions were analysed (MD1: n = 661; MD2: n = 777). In the guideline-compliant subgroup analysis, prehospital treatment by emergency physicians at MD1 hospital showed a significantly higher rate of 12-lead ECGs performed (76.9% vs. 43.5%; OR 4.31 [95% CI 3.43–5.43]; p < 0.001) and more frequent administration of ASA (91.4% vs. 70.9%; OR 4.35 [3.18–5.94]; p < 0.001) and heparin (92.6% vs. 68.0%; OR 5.89 [4.24–8.17]; p < 0.001). In patients with VAS ≥ 4, morphine was administered more frequently by emergency physicians at Clinic MD1 than by emergency physicians at Clinic MD2 (70.6% vs. 54.5%; OR 2.01 [1.33–3.05]; p < 0.001). In contrast, there were no significant differences in prehospital treatment between the emergency physicians at clinics MD1 and MD2 when nitro-glycerine and oxygen were administered as indicated. The multivariate adjusted analysis (for age and gender) confirmed these findings. In addition, the prehospital dwell time for emergency physicians at Clinic MD1 was significantly longer than for emergency physicians at Clinic MD2 (median 34 [IQR 29–39] vs. 29 [23–34] minutes; p < 0.001). Discussion This city-level analysis identified substantial variation in prehospital ACS care between the two provider structures in Magdeburg. Compared with MD2, emergency physicians at MD1 more frequently recorded a 12-lead ECG and more often administered ASA, heparin, and morphine when indicated. By contrast, no relevant differences were observed for indication-based nitroglycerine or oxygen administration. The consistency of the unadjusted and adjusted analyses suggests that these differences are unlikely to be explained solely by age or sex distributions. The higher rate of prehospital 12-lead ECG acquisition at MD1 is clinically important, because early ECG documentation structures downstream triage and reperfusion pathways in suspected ACS [9]. The same pattern applies to ASA and heparin administration, which were also more common at MD1. Taken together, these findings point less to isolated prescribing decisions than to differences in local workflow, documentation practice, and operational priorities. The longer prehospital dwell time observed at MD1 provides one plausible explanation. A modest increase in on-scene or transport-associated time may create additional opportunity for ECG acquisition, analgesia titration, and initiation of antithrombotic treatment. At the same time, this association should not be interpreted causally: a longer dwell time may enable more interventions, but it may also reflect differences in case mix, operational tempo, or team routines that were not captured in the present dataset. Team composition is another possible contributor. During the study period, MD1 was staffed exclusively by anaesthesiology physicians, whereas MD2 involved physicians from several specialties. Heterogeneous staffing does not imply lower quality, but it may increase variability in prehospital routines, familiarity with specific algorithms, and exposure to site-specific feedback and training processes. This interpretation is consistent with literature showing that implementation of prehospital standards depends not only on guidelines themselves, but also on local training structures, audit processes, and organisational context [8,13-16]. From a quality-assurance perspective, the findings are best understood as evidence of remediable process variation within one urban EMS system. Repeated audit cycles, standardised documentation rules, and focused refresher training - especially for early ECG acquisition, antithrombotic initiation, and indication-based analgesia - could reduce unwarranted between-site differences. Such measures may be more actionable than attributing the observed variation to individual specialties or isolated clinical decisions. Overall, the present data show that organisational setting matters for the prehospital implementation of guideline-based ACS care. The differences observed between MD1 and MD2 do not necessarily indicate deliberate deviation from guidelines; rather, they suggest different operational emphases within the same emergency care network. This makes the results relevant not only for local quality improvement, but also for the design of future multicentre evaluations of prehospital ACS management. Methodological limitations This study has several limitations. First, its retrospective design relies on routine documentation. Because the analysis was based on protocol entries rather than direct observation, under-documentation and differences in documentation habits between sites cannot be excluded. The use of both handwritten and electronic records may have contributed additional heterogeneity. Second, the study focused on process quality and did not assess patient-centred outcomes such as reperfusion delay, complications, or mortality. The findings therefore allow conclusions about documented prehospital management, but not about the clinical effectiveness of the observed differences. Third, not all potentially relevant confounders were available. Variables such as clinical severity, haemodynamic instability, transport distance, dispatch urgency, team composition on individual missions, and hospital destination may have influenced both treatment patterns and dwell time. In addition, some specialty-specific subgroups were small, which limits the precision of subgroup comparisons. Finally, data retrieval was logistically demanding because archived paper records had to be reviewed under restricted access conditions. These organisational constraints delayed the evaluation, but they do not change the pragmatic value of the dataset. Despite these limitations, the study provides a real-world assessment of how guideline-based ACS measures are implemented in routine prehospital emergency care. This type of protocol-based analysis remains useful for identifying concrete targets for quality assurance and implementation work. Summary and outlook: Acute coronary syndrome (ACS) is a time-critical emergency in which the prehospital implementation of guideline-based diagnosis and therapy is crucial for the treatment pathway. The aim of this bicentric observational study was to compare the prehospital quality of care provided by emergency physicians at two tertiary care hospitals in Magdeburg (University Hospital and Magdeburg Municipal Hospital) using ACS interventions from the MONAH-1 study. A total of 1,438 emergency physician interventions with typical ACS diagnoses were included. They were evaluated using predefined quality indicators (12-lead ECG, ASA, heparin, morphine, oxygen and nitroglycerine administration according to ESC guidelines) and compared using univariate and multivariate analyses adjusted for age and gender. Emergency physicians at MD1 performed 12-lead ECGs more often (76.9% vs. 43.5%; aOR 4.24 [3.36–5.35]) and administered ASA (91.4% vs. 70.9%; aOR 4.38 [3.19–6.00]), heparin (92.6% vs. 68.0%; aOR 5.86 [4.21–8.16]) and morphine for pain intensity VAS ≥ 4 (70.6% vs. 54.5%; aOR 2.67 [2.04–3.50]; p < 0.001 in each case) more frequently. However, there were no differences in prehospital treatment between the two hospitals with regard to the indication-appropriate administration of nitroglycerine and oxygen. Prehospital dwell time was longer at MD1 (median 34 vs. 29 minutes; p < 0.001) and may have facilitated additional diagnostic and therapeutic measures. Overall, the results indicate pronounced site-specific differences in care strategy and organizational structure, leading to relevant variation in the prehospital implementation of guideline-based ACS therapy without necessarily implying deliberate guideline deviations. Further studies are needed to determine whether these differences persist under current staffing structures. Declarations I declare that I have no conflicts of interest in connection with this research/study/project. I have no personal or financial relationships that could influence my work. The study was self-financed. Funding Declaration: The authors declare that no specific funding was received for the preparation of this manuscript. The research was conducted as part of the authors’ academic and/or clinical activities without external financial support. Author´s contributions: . T. Hofmann, C. Schmidt collected and evaluated the data. - T. Hofmann and P. Baumann, C. Breitling wrote the first draft of the manuscript and T. Hofmann took the lead in writing the manuscript. - M. Sauer, Th. Schilling have provided critical feedback and helped to shape the research, analysis and manuscript - F. Meyer supervised the project - T. Hofmann, F. Meyer proof-read the final version of the manuscript. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethical considerations: The patient data were recorded anonymously. In accordance with Section 16(3)(5) and Section 17 of the Hospital Act of the State of Saxony-Anhalt, the patients’ consent was not required. The name of the emergency physician was also anonymized. Only their qualification (specialist or resident) was recorded. Moreover, the specialty of each specialist and the current hospital affiliation of each resident were stored for further analyses. The study complied with the Declaration of Helsinki. Approval was obtained from the ethics committee of Otto von Guericke University with University Hospital (reference number: 73/25). The study was officially documented and listed as a retrospective study in the German Clinical Trials Register, under the following identifier: DRKS00036944. The study was registered as a retrospective study on 27 August 2025 in the German Clinical Trials Register. References Larsen R. Akutes Koronarsyndrom (ACS) und akuter Myokardinfarkt. In: Larsen R, editor. Anästhesie und Intensivmedizin für die Fachpflege. Berlin, Heidelberg: Springer Berlin Heidelberg; 2016. pp. 680–90. Steg PG, James SK. ESC POCKET GUIDELINES. Therapie des akuten Herzinfarktes bei Patienten mit persistierender ST-Streckenhebung;2012. Ibánez B, James S, Agewall S et al. (2017) 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Revista espanola de cardiologia (English ed.);70(12):1082. 10.1016/j.rec.2017.11.010 J. 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Präklinisches Management von Patienten mit akuter Angina-pectoris-Symptomatik: Eine retrospektive Datenauswertung im Hinblick auf aktuelle Leitlinien (Prehospital management of patients with suspected acute coronary syndrome : Real world experience reflecting current guidelines). Medizinische Klinik Intensivmedizin und Notfallmedizin. 2021;116(8):694–7. 10.1007/s00063-020-00739-3 . Hofmann T, Schmidt C, Meyer F et al. (2026) Unterschiede in der prähospitalen Notfallversorgung zwischen städtischen und ländlichen Regionen am Beispiel des akuten Koronarsyndroms – die MONAH1-Studie (Differences in prehospital emergency medical care between urban and rural regions based on acute coronary syndrome-the MONAH1 study). Wiener medizinische Wochenschrift (1946). 10.1007/s10354-025-01125-4 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Apr, 2026 Reviews received at journal 02 Apr, 2026 Reviews received at journal 02 Apr, 2026 Reviews received at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviewers invited by journal 24 Mar, 2026 Editor assigned by journal 24 Mar, 2026 Editor invited by journal 23 Mar, 2026 Submission checks completed at journal 20 Mar, 2026 First submitted to journal 20 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9087668","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":611420827,"identity":"9a562770-c744-471f-8f10-2363bc0f2ddf","order_by":0,"name":"Tobias Hofmann","email":"data:image/png;base64,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","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":true,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Hofmann","suffix":""},{"id":611420828,"identity":"972b3206-137a-4401-a8ff-9415e67f7064","order_by":1,"name":"Peter Baumann","email":"","orcid":"","institution":"Klinikum Magdeburg gGmbH","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Baumann","suffix":""},{"id":611420829,"identity":"c2b4ba1d-48d0-4cce-a34c-de86fa576d72","order_by":2,"name":"Martin Sauer","email":"","orcid":"","institution":"Klinikum Magdeburg gGmbH","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Sauer","suffix":""},{"id":611420830,"identity":"a267f7a0-b822-41b0-85bd-c9fd12ac3b58","order_by":3,"name":"Thomas Schilling","email":"","orcid":"","institution":"Klinikum Magdeburg gGmbH","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Schilling","suffix":""},{"id":611420831,"identity":"1ef7c903-731f-4d41-b051-9c4735d4f8aa","order_by":4,"name":"Christian Breitling","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Breitling","suffix":""},{"id":611420832,"identity":"4eda097e-0ba8-4b5a-b5bc-7f96fec84f50","order_by":5,"name":"Claudia Schmidt","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"Claudia","middleName":"","lastName":"Schmidt","suffix":""},{"id":611420833,"identity":"78861356-c5ab-4f11-bf58-55e4e0c8ca6d","order_by":6,"name":"Frank Meyer","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Meyer","suffix":""}],"badges":[],"createdAt":"2026-03-10 20:53:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9087668/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9087668/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105566563,"identity":"47b3cc17-f7ad-4e60-84bb-538cd7d996cf","added_by":"auto","created_at":"2026-03-27 12:56:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":604242,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9087668/v1/f77b505a-012d-48af-89f3-3d7919c3bfef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Are there any differences in prehospital ACS care within one city? Comparison of prehospital care provided by emergency physicians from two tertiary care hospitals. Further evaluations of the “MONAH-1” study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute coronary syndrome (ACS) is one of the most time-critical medical emergencies, in which early diagnosis and guideline-based therapy are crucial for the morbidity and mortality of those affected. Even in the prehospital setting, the emergency physician can take essential measures, including structured clinical assessment, recording and interpretation of a 12-lead electrocardiogram, and early initiation of evidence-based drug therapy. Prehospital care quality thus plays a key role in the overall treatment pathway of patients with ACS. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn Magdeburg, the capital of Saxony-Anhalt, three EMS physician bases are staffed 24/7 to ensure emergency care for the population. Two hospitals provide the emergency physician staffing. During the period under review, one base was staffed by Magdeburg University Hospital (MD1) and two EMS physician bases by Magdeburg Hospital (MD2). Against this background, the standardised clinical picture of acute coronary syndrome provides a suitable basis for the objective assessment of prehospital care quality.\u003c/p\u003e \u003cp\u003eThe objective of this study was to analyse and compare the quality of prehospital care provided by the emergency physicians at the two hospitals in Magdeburg. The study is based on prehospital care data collected from ACS patients as part of the MONAH-1 study. The comparison aims to provide information on the extent to which guideline-compliant measures and care standards are implemented in the prehospital setting and whether there are any relevant differences between the participating providers.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting:\u003c/h2\u003e \u003cp\u003eThis manuscript reports a prespecified Magdeburg subgroup analysis of MONAH-1, a retrospective bicentric observational study on prehospital emergency physician management of suspected acute coronary syndrome (ACS). The overall MONAH-1 design, case-identification strategy, and protocol-based extraction approach have been described previously in the published region-based comparison by Hofmann et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the present analysis, only cases managed at the three EMS physician bases in Magdeburg were evaluated.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGuideline basis and quality indicators:\u003c/h3\u003e\n\u003cp\u003eGuideline adherence was assessed against the European Society of Cardiology recommendations applicable during the study period (2014\u0026ndash;2018) for ST-elevation myocardial infarction and non-ST-elevation ACS [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. From these documents, predefined process indicators were derived for statistical evaluation: acquisition of a 12-lead ECG; administration of acetylsalicylic acid (ASA) and heparin; morphine in patients with relevant pain; oxygen in hypoxaemia; and nitro-glycerine when clinically indicated. Drug selection, indications, and dosing were interpreted according to the contemporaneous guideline documents [\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eCase identification:\u003c/h3\u003e\n\u003cp\u003eAll consecutive prehospital emergency physician missions in Magdeburg between 2014 and 2018 were screened. Cases were included when the protocol documented ACS, STEMI, NSTEMI, unstable angina, myocardial infarction, or acute myocardial infarction. Missions performed by the rescue helicopter Christoph 36 were excluded because these deployments do not reflect routine ground-based emergency physician coverage and the corresponding records were not available for evaluation for data-protection reasons.\u003c/p\u003e\n\u003ch3\u003eSetting:\u003c/h3\u003e\n\u003cp\u003eDuring the study period, one Magdeburg EMS physician base was staffed by Magdeburg University Hospital (MD1), whereas two bases were staffed by Magdeburg Municipal Hospital (MD2). Thus, the comparison reflects two provider structures operating within the same urban emergency medical service system.\u003c/p\u003e\n\u003ch3\u003eData acquisition and handling of missing data:\u003c/h3\u003e\n\u003cp\u003eEmergency physician protocols from the study period were reviewed in paper or electronic form, depending on the respective base and year of documentation. Both structured check boxes and free-text entries were used to identify diagnoses and prehospital measures. Tactical and demographic variables were analysed only when documented. For treatment-related variables, absence of documentation was classified as \"not documented\"/not performed for the purpose of process evaluation. For example, a 12-lead ECG was counted only when ECG acquisition or corresponding findings were explicitly recorded in the structured fields or free text. This rule was defined a priori and is consistent with the medico-legal principle that undocumented measures cannot be assumed to have been performed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were entered into Microsoft Excel and analysed with IBM SPSS Statistics version 29. Categorical variables are reported as absolute and relative frequencies and were compared using chi-square tests or Fisher's exact tests as appropriate. Continuous variables are presented as medians with interquartile ranges and were compared using the Mann-Whitney U test. To examine whether the EMS physician location was independently associated with selected prehospital measures, multivariable logistic regression models were calculated with adjustment for age and sex. Results are reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All statistical tests were two-sided, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,438 emergency physician protocols were used for statistical analysis in this article. Of these, 661 patients were treated by emergency physicians at the University Hospital (MD1) and 777 patients were treated by emergency physicians at Magdeburg Hospital (MD2). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e show the patient characteristics (gender distribution, age) and emergency physician characteristics (specialisation and qualifications of the emergency physicians deployed).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMD1 (n\u0026thinsp;=\u0026thinsp;661)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD2 (n\u0026thinsp;=\u0026thinsp;777)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (min\u0026ndash;max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u0026ndash;99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e375 (56.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e483 (62.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e286 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e286 (37.2%)\u003c/p\u003e \u003cp\u003e8 (1,0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eContinuous variables were compared using the Mann\u0026ndash;Whitney U test. Categorical variables were compared using the chi-square test. A two-sided p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEmergency physician characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMD1 (n\u0026thinsp;=\u0026thinsp;661)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD2 (n\u0026thinsp;=\u0026thinsp;777)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpeciality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e661 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e565 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e128 (16.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQualification, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e369 (55.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e347 (44.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e292 (44.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e416 (53.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCategorical variables were compared using the chi-square test. A two-sided p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003cp\u003eGM: general medicine; AN: anaesthesia; SU: surgery; IM: internal medicine; UK: unknown; R: resident; S: specialist\u003c/p\u003e \u003cp\u003eFurther analyses revealed differences in prehospital treatment with regard to therapeutic and diagnostic measures between the emergency physicians at the hospitals under review.\u003c/p\u003e \u003cp\u003eThe subgroup analysis showed that emergency physicians at MD1 performed 12-lead ECGs more often than emergency physicians at MD2 (76.9% vs. 43.5%; OR 4.31 [95% CI 3.43\u0026ndash;5.43]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The administration of ASA (91.4% vs. 70.9%; OR 4.35 [3.18\u0026ndash;5.94]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and heparin (92.6% vs. 68.0%; OR 5.89 [4.24\u0026ndash;8.17]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was also more common among emergency physicians at MD1.\u003c/p\u003e \u003cp\u003eIn patients with pain intensity of VAS\u0026thinsp;\u0026ge;\u0026thinsp;4, morphine was administered by emergency physicians at MD1 in 70.6% of cases, compared with 54.5% by emergency physicians at MD2 (OR 2.01 [1.33\u0026ndash;3.05]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, there were no differences between the emergency physicians at the two hospitals in the indication-appropriate administration of nitro-glycerine (50.6% vs. 54.8%; OR 0.85 [0.68\u0026ndash;1.05]; p\u0026thinsp;=\u0026thinsp;0.136) and or oxygen (72.7% vs. 78.5%; OR 0.73 [0.33\u0026ndash;1.63]; p\u0026thinsp;=\u0026thinsp;0.445). The results are given in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeasures taken (subgroup analysis) in MD1 and MD2.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMD1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12-lead ECG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e508/661 (76.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e338/777 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.31 (3.43\u0026ndash;5.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMorphine administration (only VAS\u0026thinsp;\u0026ge;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e279/395 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67/123 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.01 (1.33\u0026ndash;3.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNitro-glycerine administration when indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e313/618 (50.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e386/705 (54.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.85 (0.68\u0026ndash;1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA administration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e604/661 (91.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e551/777 (70.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.35 (3.18\u0026ndash;5.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeparin administration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e612/661 (92.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e528/777 (68.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.89 (4.24\u0026ndash;8.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxygen administration when indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48/66 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51/65 (78.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73 (0.33\u0026ndash;1.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: Values as n/N (%). Odds ratio (OR) for MD1 compared to MD2. p-values from chi-square test; for small expected frequencies, Fisher's exact test. 95% confidence intervals of OR according to Woolf; for zero cells, Haldane-Anscombe correction\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe multivariate adjusted analysis (adjustment for age and gender) confirmed these results. Emergency physicians at the MD1 clinic continued to perform 12-lead ECGs significantly more often (aOR 4.24 [3.36\u0026ndash;5.35]), and to administer ASA (aOR 4.38 [3.19\u0026ndash;6.00]), heparin (aOR 5.86 [4.21\u0026ndash;8.16]) and morphine for appropriate indications (aOR 2.67 [2.04\u0026ndash;3.50]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 in each case) significantly more often. There were no differences even after adjustment for O₂ administration in cases of hypoxaemia (aOR 0.76 [0.33\u0026ndash;1.74]; p\u0026thinsp;=\u0026thinsp;0.516) and nitroglycerine administration in cases of elevated blood pressure (aOR 0.84 [0.67\u0026ndash;1.04]; p\u0026thinsp;=\u0026thinsp;0.110). These results are shown in Table\u0026nbsp;4.\u003c/p\u003e \u003cp\u003eTable 4: Multivariate analysis MD1 vs. MD2 – prehospital treatment (adjusted for age and gender)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (in model)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12-lead ECG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.24 (3.36–5.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eASA administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.38 (3.19–6.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHeparin administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.86 (4.21–8.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMorphine administration when indicated (pain documented)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e922\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.67 (2.04–3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eO₂ administration when indicated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.76 (0.33–1.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNitro-glycerine administration when indicated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.84 (0.67–1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: aOR = adjusted odds ratio; CI = confidence interval\u003c/p\u003e\n\u003cp\u003eTo explore a possible explanation for the differences in prehospital treatment between the emergency physicians at clinics MD1 and MD2, the PHVZ (prehospital dwell time) was analysed. This was defined as the time from arrival at the patient to handover at the hospital. It differed significantly between the two locations. Emergency physicians at hospital MD1 had a longer PHVZ than emergency physicians at hospital MD2 (median 34 [IQR 29–39] vs. 29 [23–34] minutes; p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eSummary of results:\u003c/p\u003e\n\u003cp\u003eA total of 1,438 emergency physician interventions were analysed (MD1: n = 661; MD2: n = 777). In the guideline-compliant subgroup analysis, prehospital treatment by emergency physicians at MD1 hospital showed a significantly higher rate of 12-lead ECGs performed (76.9% vs. 43.5%; OR 4.31 [95% CI 3.43–5.43]; p \u0026lt; 0.001) and more frequent administration of ASA (91.4% vs. 70.9%; OR 4.35 [3.18–5.94]; p \u0026lt; 0.001) and heparin (92.6% vs. 68.0%; OR 5.89 [4.24–8.17]; p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eIn patients with VAS ≥ 4, morphine was administered more frequently by emergency physicians at Clinic MD1 than by emergency physicians at Clinic MD2 (70.6% vs. 54.5%; OR 2.01 [1.33–3.05]; p \u0026lt; 0.001). In contrast, there were no significant differences in prehospital treatment between the emergency physicians at clinics MD1 and MD2 when nitro-glycerine and oxygen were administered as indicated.\u003c/p\u003e\n\u003cp\u003eThe multivariate adjusted analysis (for age and gender) confirmed these findings. In addition, the prehospital dwell time for emergency physicians at Clinic MD1 was significantly longer than for emergency physicians at Clinic MD2 (median 34 [IQR 29–39] vs. 29 [23–34] minutes; p \u0026lt; 0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis city-level analysis identified substantial variation in prehospital ACS care between the two provider structures in Magdeburg. Compared with MD2, emergency physicians at MD1 more frequently recorded a 12-lead ECG and more often administered ASA, heparin, and morphine when indicated. By contrast, no relevant differences were observed for indication-based nitroglycerine or oxygen administration. The consistency of the unadjusted and adjusted analyses suggests that these differences are unlikely to be explained solely by age or sex distributions.\u003c/p\u003e\n\u003cp\u003eThe higher rate of prehospital 12-lead ECG acquisition at MD1 is clinically important, because early ECG documentation structures downstream triage and reperfusion pathways in suspected ACS [9]. The same pattern applies to ASA and heparin administration, which were also more common at MD1. Taken together, these findings point less to isolated prescribing decisions than to differences in local workflow, documentation practice, and operational priorities.\u003c/p\u003e\n\u003cp\u003eThe longer prehospital dwell time observed at MD1 provides one plausible explanation. A modest increase in on-scene or transport-associated time may create additional opportunity for ECG acquisition, analgesia titration, and initiation of antithrombotic treatment. At the same time, this association should not be interpreted causally: a longer dwell time may enable more interventions, but it may also reflect differences in case mix, operational tempo, or team routines that were not captured in the present dataset.\u003c/p\u003e\n\u003cp\u003eTeam composition is another possible contributor. During the study period, MD1 was staffed exclusively by anaesthesiology physicians, whereas MD2 involved physicians from several specialties. Heterogeneous staffing does not imply lower quality, but it may increase variability in prehospital routines, familiarity with specific algorithms, and exposure to site-specific feedback and training processes. This interpretation is consistent with literature showing that implementation of prehospital standards depends not only on guidelines themselves, but also on local training structures, audit processes, and organisational context [8,13-16].\u003c/p\u003e\n\u003cp\u003eFrom a quality-assurance perspective, the findings are best understood as evidence of remediable process variation within one urban EMS system. Repeated audit cycles, standardised documentation rules, and focused refresher training - especially for early ECG acquisition, antithrombotic initiation, and indication-based analgesia - could reduce unwarranted between-site differences. Such measures may be more actionable than attributing the observed variation to individual specialties or isolated clinical decisions.\u003c/p\u003e\n\u003cp\u003eOverall, the present data show that organisational setting matters for the prehospital implementation of guideline-based ACS care. The differences observed between MD1 and MD2 do not necessarily indicate deliberate deviation from guidelines; rather, they suggest different operational emphases within the same emergency care network. This makes the results relevant not only for local quality improvement, but also for the design of future multicentre evaluations of prehospital ACS management.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethodological limitations\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, its retrospective design relies on routine documentation. Because the analysis was based on protocol entries rather than direct observation, under-documentation and differences in documentation habits between sites cannot be excluded. The use of both handwritten and electronic records may have contributed additional heterogeneity.\u003c/p\u003e\n\u003cp\u003eSecond, the study focused on process quality and did not assess patient-centred outcomes such as reperfusion delay, complications, or mortality. The findings therefore allow conclusions about documented prehospital management, but not about the clinical effectiveness of the observed differences.\u003c/p\u003e\n\u003cp\u003eThird, not all potentially relevant confounders were available. Variables such as clinical severity, haemodynamic instability, transport distance, dispatch urgency, team composition on individual missions, and hospital destination may have influenced both treatment patterns and dwell time. In addition, some specialty-specific subgroups were small, which limits the precision of subgroup comparisons.\u003c/p\u003e\n\u003cp\u003eFinally, data retrieval was logistically demanding because archived paper records had to be reviewed under restricted access conditions. These organisational constraints delayed the evaluation, but they do not change the pragmatic value of the dataset.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, the study provides a real-world assessment of how guideline-based ACS measures are implemented in routine prehospital emergency care. This type of protocol-based analysis remains useful for identifying concrete targets for quality assurance and implementation work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSummary and outlook:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAcute coronary syndrome (ACS) is a time-critical emergency in which the prehospital implementation of guideline-based diagnosis and therapy is crucial for the treatment pathway. The aim of this bicentric observational study was to compare the prehospital quality of care provided by emergency physicians at two tertiary care hospitals in Magdeburg (University Hospital and Magdeburg Municipal Hospital) using ACS interventions from the MONAH-1 study. A total of 1,438 emergency physician interventions with typical ACS diagnoses were included. They were evaluated using predefined quality indicators (12-lead ECG, ASA, heparin, morphine, oxygen and nitroglycerine administration according to ESC guidelines) and compared using univariate and multivariate analyses adjusted for age and gender. Emergency physicians at MD1 performed 12-lead ECGs more often (76.9% vs. 43.5%; aOR 4.24 [3.36\u0026ndash;5.35]) and administered ASA (91.4% vs. 70.9%; aOR 4.38 [3.19\u0026ndash;6.00]), heparin (92.6% vs. 68.0%; aOR 5.86 [4.21\u0026ndash;8.16]) and morphine for pain intensity VAS \u0026ge; 4 (70.6% vs. 54.5%; aOR 2.67 [2.04\u0026ndash;3.50]; p \u0026lt; 0.001 in each case) more frequently. However, there were no differences in prehospital treatment between the two hospitals with regard to the indication-appropriate administration of nitroglycerine and oxygen. Prehospital dwell time was longer at MD1 (median 34 vs. 29 minutes; p \u0026lt; 0.001) and may have facilitated additional diagnostic and therapeutic measures. Overall, the results indicate pronounced site-specific differences in care strategy and organizational structure, leading to relevant variation in the prehospital implementation of guideline-based ACS therapy without necessarily implying deliberate guideline deviations. Further studies are needed to determine whether these differences persist under current staffing structures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eI declare that I have no conflicts of interest in connection with this research/study/project. I have no personal or financial relationships that could influence my work.\u003c/p\u003e\n\u003cp\u003eThe study was self-financed.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding Declaration:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no specific funding was received for the preparation of this manuscript. The research was conducted as part of the authors\u0026rsquo; academic and/or clinical activities without external financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor\u0026acute;s contributions:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e. T. Hofmann, C. Schmidt collected and evaluated the data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- T. Hofmann and P. Baumann, C. Breitling wrote the first draft of the manuscript and T. Hofmann took the lead in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e- M. Sauer, Th. Schilling have provided critical feedback and helped to shape the research, analysis and manuscript\u003c/p\u003e\n\u003cp\u003e- F. Meyer supervised the project\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- T. Hofmann, F. Meyer proof-read the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthical considerations:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient data were recorded anonymously. In accordance with Section 16(3)(5) and Section 17 of the Hospital Act of the State of Saxony-Anhalt, the patients\u0026rsquo; consent was not required.\u003c/p\u003e\n\u003cp\u003eThe name of the emergency physician was also anonymized. Only their qualification (specialist or resident) was recorded. Moreover, the specialty of each specialist and the current hospital affiliation of each resident were stored for further analyses.\u003c/p\u003e\n\u003cp\u003eThe study complied with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eApproval was obtained from the ethics committee of Otto von Guericke University with University Hospital (reference number: 73/25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was officially documented and listed as a retrospective study in the German Clinical Trials Register, under the following identifier: DRKS00036944. 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Wiener medizinische Wochenschrift (1946). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10354-025-01125-4\u003c/span\u003e\u003cspan address=\"10.1007/s10354-025-01125-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"prehospital care, MONAH-1 study, ACS, emergency physicians","lastPublishedDoi":"10.21203/rs.3.rs-9087668/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9087668/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAcute coronary syndrome (ACS) is a time-critical medical emergency in which early guideline-based prehospital diagnosis and treatment are crucial for the further course of treatment. The aim of this study was to compare the quality of prehospital care provided by emergency physicians at two maximum care hospitals in Magdeburg.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAs part of the retrospective, bicentric observational study MONAH-1, all prehospital physician missions with typical ACS diagnoses in Magdeburg between 2014 and 2018 were analysed. Using defined quality indicators in accordance with ESC guidelines (including 12-lead ECG, administration of acetylsalicylic acid (ASA), heparin, morphine, oxygen and nitro-glycerine), a comparison was made between emergency physicians at the University Medical Centre (MD1) and Magdeburg Hospital (MD2). The statistical analysis included univariate and multivariate logistic regression analyses adjusted for age and gender.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 1,438 emergency physician interventions were evaluated (MD1: n\u0026thinsp;=\u0026thinsp;661; MD2: n\u0026thinsp;=\u0026thinsp;777). Emergency physicians at MD1 performed 12-lead ECGs significantly more often (76.9% vs. 43.5%; aOR 4.24 [95% CI 3.36\u0026ndash;5.35]), administered ASA more often (91.4% vs. 70.9%; aOR 4.38 [3.19\u0026ndash;6.00]) and heparin (92.6% vs. 68.0%; aOR 5.86 [4.21\u0026ndash;8.16]) more frequently, and administered morphine for pain intensity VAS\u0026thinsp;\u0026ge;\u0026thinsp;4 (70.6% vs. 54.5%; aOR 2.67 [2.04\u0026ndash;3.50]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 in each case). No significant differences were found for the indication-appropriate administration of nitro-glycerine and oxygen. The prehospital dwell time was longer in MD1 (median 34 vs. 29 minutes; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePrehospital care for ACS patients differed between the two emergency medical service locations. Emergency physicians at MD1 implemented guideline-recommended diagnostic and therapeutic measures more frequently, possibly facilitated by a longer prehospital dwell time and location-specific organisational structures. The results underscore the influence of organisational conditions on the quality of prehospital care and provide starting points for future quality assurance measures.\u003c/p\u003e","manuscriptTitle":"Are there any differences in prehospital ACS care within one city? Comparison of prehospital care provided by emergency physicians from two tertiary care hospitals. Further evaluations of the “MONAH-1” study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-26 09:06:44","doi":"10.21203/rs.3.rs-9087668/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T04:12:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T17:37:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T14:42:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T12:29:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181337787610810584774910373822886206066","date":"2026-04-02T12:14:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24791503837544726587446945895932574382","date":"2026-04-02T08:20:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265390693120615088314904611738613556887","date":"2026-04-02T08:17:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223013620029104546132399706694203528504","date":"2026-04-01T00:29:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-24T11:36:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-24T11:18:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-23T05:38:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-20T22:18:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-03-20T22:14:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95f59da0-bca2-42d8-b507-945d8042c2d7","owner":[],"postedDate":"March 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-10T18:09:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-26 09:06:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9087668","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9087668","identity":"rs-9087668","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}