Crisis Resource Management (CRM)

OVERVIEW

• Crisis Resource Management (CRM) refers to the non-technical skills required for effective teamwork in a crisis situation
• In addition to the nature of the task itself, numerous factors affect the performance of complex tasks at the level of the individual, team and the environment
• CRM originated with Crew (or ‘Cockpit’) Resource Management training developed by the aviation industry in the 1970s following the realisation that 70% of airline crashes were due to human error resulting from teamwork failure
• CRM training improves performance and reduces errors (settings include the emergency department, trauma teams and rapid response teams)

FACTORS AFFECTING THE PERFORMANCE OF COMPLEX TASKS

Task

• complexity
• high stakes (e.g. life-threatening illness; medico-legal implications)
• time-critical
• incomplete information

Individual (e.g. HALTS – hungry, angry, late, tired or stressed)

• Fatigue
• Sleep deprivation
• Emotional disturbance (e.g. angry, stressed)
• Ill health and physical distress
• Inexperience
• Lack of knowledge

Team

• Role confusion
• High power distance/ authority gradient
• Ineffective communication techniques
• Dysfunctional relationships

Environment

• Interruptions
• Noise
• Handovers
• Production pressure (e.g. deadlines, quotas)
• Equipment failure
• Unfamiliar place and equipment

KEY PRINCIPLES OF CRM

Rall and Gaba (2005) have identified the followed 15 key principles:

1. Know the environment
2. Anticipate and plan
3. Call for help early
4. Exercise leadership and followership
5. Distribute the workload
6. Mobilise all available resources
7. Communicate effectively
8. Use all available information
9. Prevent and manage fixation errors
10. Cross (double) check
11. Use cognitive aids
12. Re-evaluate repeatedly
13. Use good teamwork
14. Allocate attention wisely
15. Set priorities dynamically

However, I prefer to nest these key principles under the following headings:

1. Know your environment
2. Anticipate, share and review the plan
3. Provide effective leadership
4. Ensure role clarity and good teamwork
5. Communicate effectively
6. Call for help early
7. Allocate attention wisely – avoid fixation
8. Distribute the workload – monitor and support team members

KNOW YOUR ENVIRONMENT

• Know the location and function of equipment, especially for time-critical procedures
• Logically structured, well-labelled environment
• Use cognitive aids, e.g. equipment maps
• Regular training
• Know the role and level of experience of team members (role confusion is common in the resus room setting)

ANTICIPATE, SHARE AND REVIEW THE PLAN

• Think ahead and plan for all contingencies
• Set priorities dynamically
• Re-evaluate periodically
• Anticipate delays
• Use call-and-respond checklists
• Share the plan with others – sharing the mental model facilitates effective action towards a common goal
• Think out loud and provide periodic briefings to verbalise priorities, goals and clinical findings as they change
• Encourage team members to share relevant thoughts and plans
• Continually review the plan based on observations and response to treatment

PROVIDE EFFECTIVE LEADERSHIP

• Employ the least confrontational approach consistent with the goal
• Participative decision making improves team buy in
• Use a direct, authoritative approach when necessary (e.g. time critical situations)
• Establish behavioural and performance expectations of team members
• Establish and maintain the team’s shared mental model of what is happening and the team’s goals
• Monitor the external and internal environments of the team to avoid being caught off guard
• Leader provides debriefing after the crisis

ENSURE ROLE CLARITY AND GOOD TEAMWORK

• Allocate team roles
• If team roles are changed during a task, ensure there is explicit handover (e.g. “Joanna will take over as team leader, while I help with the difficult airway”)
• Team members should show good followership and be active – each observes and monitors events and advocates or asserts corrective actions
• Team members including the Leader need to be able to recognise when they are affected by stress, and develop appropriate self-care behaviours
• All team members – Leaders and Followers – are equally responsible for ensuring good patient outcomes

COMMUNICATE EFFECTIVELY

• Distribute needed information to team members and update the shared mental model
• Use closed loop communication
• Be assertive, not aggressive or submissive
• Avoid personal attacks
• Resolve conflict
• Maintain relationships
• Facilitate collaborative efforts working towards a common goal
• Cross (double) check with team members
• Avoid unnecessary mitigating language (‘whimperatives’, e.g. “if possible, would you mind attempting an IV cannula, if that is not too much trouble?)

CALL FOR HELP EARLY

• Be aware of barriers to asking for help (e.g. fear of criticism or losing face)
• Set predefined criteria for asking for help
• Call for help early
• Mobilize all available resources

ALLOCATE ATTENTION WISELY – AVOID FIXATION

• Be aware of ‘fixation error’ that reduces situational awareness
• Prioritize tasks and focus on the most important task at hand
• Delegate tasks to others
• Use all available information
• Ensure monitors are continually observed and assessments repeated periodically (e.g. blood pressure cuff set to auto-cycle every 2 minutes)

DISTRIBUTE THE WORKLOAD – MONITOR AND SUPPORT TEAM MEMBERS

• Team Leader is ‘hands off’ — stands back whenever possible to maintain situational awareness and oversee the team
• Assign tasks according to the defined roles of the team
• Team Leader supports team members in their tasks
• Reallocate roles as tasks are completed or evolve in complexity

VIDEO

Dr Christopher Gallagher illustrates the basics of CRM:

References and Links

LITFL

• CCC — Communication in a Crisis
• Jo Deverill — Crisis, Crewmanship and CRM (2014)
• Tamara Hills at smaccGOLD (includes the video ’17 minutes’) (2014)

Journal Articles and Textbooks

• Bleetman A, Sanusi S, Dale T, Brace S. Human factors and error prevention in emergency medicine. Emerg Med J. 2012 May;29(5):389-93. doi: 10.1136/emj.2010.107698. Epub 2011 May 12. Review. PubMed PMID: 21565880.
• Carne B, Kennedy M, Gray T. Review article: Crisis resource management in emergency medicine. Emerg Med Australas. 2012 Feb;24(1):7-13. doi: 10.1111/j.1742-6723.2011.01495.x. Epub 2011 Oct 13. Review. PubMed PMID: 22313554.
• Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth. 2010 Jul;105(1):3-6. doi: 10.1093/bja/aeq124. PubMed PMID: 20551023. [Free Full Text]
• Haerkens MH, Jenkins DH, van der Hoeven JG. Crew resource management in the ICU: the need for culture change. Ann Intensive Care. 2012 Aug 22;2(1):39. doi: 10.1186/2110-5820-2-39. PubMed PMID: 22913855; PubMed Central PMCID: PMC3488012.
• Rall M, Gaba DM. Human Performance and Patient Safety, in Miller’s Anaesthesia, 6th edition, Elsevier, 2005
• Reason J. Understanding adverse events: human factors. Qual Health Care. 1995 Jun;4(2):80-9. PubMed PMID: 10151618; PubMed Central PMCID: PMC1055294.
• St Pierre M, Hofinger G, Buerschaper C, Simon R. Crisis Management in Acute Care Settings: Human Factors, Team Psychology, and Patient Safety in a High Stakes Environment. (2nd edn) Springer, 2011.

FOAM and Web Resources

• ALIEM — Crisis Resource Management (2013)
• Resus.ME — The Resus Room Life Guard (2013)
• Resus.E — Learning to speak Resuscitese (2016)
• Resus Room Management — Why CRM should’t be used in Emergency Medicine – Part 1 (2013)