Introduction
Emergency medicine is, by its nature and uncertain environment, a risky activity.1 2 More specifically, medical regulation has the daily challenge of responding appropriately and effectively to emergency medical calls; when necessary, it must send the appropriate resource as fast as possible. This particular exercise is recognised as telemedicine and is based on validated procedures and recommendations.1 3–5
Urgent call management and emergency medical aid organisation are specific to each country. Some have adopted a single emergency number, such as the UK with 999,6 the USA with 9117 and Europe with 112.8 Depending on the type of emergency, an appropriate unit is sent and transmissions are made with the nearest emergency service when necessary. However, many countries still have three separate numbers for emergency, depending on whether the emergency comes under urgent medical aid, police or fire department; each of them has its own call centre and mobile units.9
This is the case in France, where emergency medical calls are centralised into emergency medical call centres, known as CRRAs (Centres de Réception et de Régulation des Appels).10 Operational 24/7 via the call number ‘15’, a medical regulation assistant (ARM) receives calls before the expertise of a regulator doctor (MR), who can be either an emergency physician or a general practitioner, depending on the type of emergency to manage.3 The CRRA is an integral part of the emergency medical assistance service called SAMU (Service d’Aide Médicale Urgente) in France, whose mission is to make decisions on how to best handle various medical situations. These can range from giving a simple telephone advice to sending mobile emergency and resuscitation unit, to quickly bringing sick persons or victims to appropriate hospitals while providing first aid.10
Medical regulation practices are associated with serious adverse events. These incidents are specific and particularly complex due to the telephone treatment of medical calls and the intervention of non-medical services (firefighters, medical transport, police).1
The recent French context, marked by the ‘tragedy of Strasbourg’ in December 2017,11 as well as several complaints for non-assistance to people in danger relayed in the French press, has highlighted this complexity as well as the lack of security in the work of agents handling calls. In addition, terrorist attacks underline the role of medical regulation in health response coordination.
The number of calls to SAMU keeps increasing (about 31 million calls for 67 million inhabitants in France in 2017; +20% between 2013 and 201712), which shows high expectations from the public1 13 and increases the pressure felt by the agents to offer effective and quality service and ensure the ‘right care’.13
Nevertheless, in France, no formalised and harmonised quality approach exists in CRRAs. Medical regulation does not appear in certification processes.1 Emergency medical societies have proposed activity and performance indicators, but the resulting lists are non-exhaustive, unstructured3–5 and their use heterogeneous between CRRAs.1
International literature on the effectiveness and precision of the responses provided is quite rich, especially concerning cardiorespiratory arrests,14–17 but very poor in terms of quality approach and evaluation. Studies exist on quality and indicators identification concerning prehospital urgent care18 19 or emergency services,20 but not concerning the previous step, which is the reception and regulation of urgent calls. Performance seems to take precedence over global quality.
As a result, it seems urgent to propose a structured list of quality indicators for medical regulation, concerning human and material resources, activity, performance and quality of calls, in the form of a dashboard. This tool is designed to follow the progress of the quality approach, assess it, identify areas for improvement and pilot actions.21 With this in mind, considering stakeholder opinion and experience in seeking consensus seems necessary in developing and prioritising a set of quality indicators. The objective of this work is to build an operational quality dashboard for CRRAs by searching for consensus on a regional scale.