Crisis Resource Management
One of my work colleagues, sent me a tweet a few days ago about an arrest he had been involved in.
There were some problems with the airway and the difficulty encountered with the moving target as CPR is ongoing. I suggested that someone should be holding the head whilst my colleague attempted to tube the patient, and this brought up the subject of Crisis Resource Management (CRM).
This got me looking at this issue as it relates to the emergency situation and I have found a number of useful resources. I have found a few definitions of what this means but I think this one includes most issues:
“Crisis Resource Management (CRM) in Healthcare promotes safety by addressing the behavioural and cognitive skills needed to effectively manage all available resources, especially during a crisis situation. This can be accomplished through the development of superior non-technical skills such communication, teamwork, situational awareness, and leadership.”
McMaster University 2014 http://simulation.mcmaster.ca/crmproject.html
As you can see, CRM focuses on non technical skills rather than the abilities to intubate, cannulate etc. With the increasing ability to simulate processes there are many courses in place now to practice this skill, and it is a skill.
I want to break down one of the resources I have found and the issues it raises.
Christopher J. Gallagher
MD Professor of Anesthesiology and Director of the Residency Training Program at the StateUniversity of New York at Stony Brook.
I found this video on Life in The Fast Lane, which goes through some great examples of the issues involved.
He breaks down CRM in to five simple stages:
- Recognise this is serious and call for help.
This should be something that you do very early. We all need to realise that we have our limitations and should never be afraid to call for some back up
2.Close the loop in communicating.
Give specific instructions to specific people! In the video people also repeat these instructions back to him. It makes it very clear what is expected of each team member and also that they all understand the tasks involved. Those team members also need to then communicate back to the team leader when they have completed their task. ‘Don’t just throw ideas out there, you want to close the loop in communicating’.
3.Establish a leader
Lack of a leader causes chaos! Someone needs to establish themselves as a leader to give the team the necessary direction. Information should come from, and go through the leader. The leader might be the most senior person there, but it may also be that they are not always the most appropriate person to lead.
4.Use resources appropriately
Identify the skills each team member has and allocate the tasks accordingly. Anaesthesia would manage the airway, ED registrar would insert the chest drain for example.
5. Step back and do a global assessment.
Re-evaluation of the situation. Physically move back from the environment so that the whole process can be reviewed. Ask review questions of your team members getting them to clarify what is happening with their task and whether they have anything to add to your thought processes.
The aviation industry, with its great need for safety, has long been a checklist culture and when the cognitive and interpersonal skills are tested in a simulated environment they are known as non-technical skills. The focus is then on the ability of the team to manage their interactions and approach to the situation, rather than their ability to insert a cannula for example. These skills are broken down into four categories and I think these can relate well to the approach taken by Dr Gallagher above:
- Leadership and managerial skills
- Situational awareness
- Decision making
Communication is assumed to run through all elements. Its true to say that all these categories play a part in the medical crisis resource management.
So why do things go wrong. Perhaps the easiest way to assess this is to look at Dr Gallagher’s methods as if you were deliberately trying to do things wrong:
- Try to manage the situation either by ones self or with an inappropriate team. There has to be a need for all staff to be aware of their limitations when in a situation they may not usually face. They then have the confidence to admit to their shortcomings, which may be hard when they are the senior member of the team, and call for help.
- Firing off commands to everybody and anybody is not only counterproductive but it makes it quickly obvious to those around you that you are not an effective leader. Those instructions should be targeted and specific – ‘John, I want you to put in a large cannula, then give a fluid bolus and let me know when that is done’
- No-one takes charge. I have been in situations where I have not been the most senior member of the team, but I have had to take charge, and announce that I was doing so because the most senior member of the team had not done so. I can confidently say that you will be aware of a group sense of relief when someone comes into the environment who seems to want to be a good leader.
- People are asked to do things they are not able to. This could be because the team members have not identified themselves to each other or because the team leader has not taken charge, so people are doing what ever is closest to them rather than being allocated appropriate tasks.
- The leader, if there is one, is too close to the situation to have an overall understanding of what is occurring elsewhere. When teaching students in the stressful environment to lead the situation I always encourage them, once the necessary help has arrived, to go the end of the bed and take a step back.
So leadership is key in the crisis, and someone has to be brave enough to take it on. I regularly attend the arrest situation and often arrive when the situation is not clear. It often involves very junior doctors and nurses who are usually very glad to have someone who will act appropriately. My approach to management of the team involves:
- First do a quick A-E assessment to ensure that we have taken the right initial steps. My eyes will always go to the patients head first then work down. If I need to be involved because the airway is not being managed properly then that is where I will go.
- If I am happy with the A-E assessment, and this can take a matter of seconds, I will then verbally establish who is in charge or leading the situation. This can often be met with a stony silence. I may ask someone if they would wish to lead it, but if time does not allow then I will assume leadership of the situation. This does not mean I am the most appropriate person to make the medical situations, but I am the most capable at prioritising the tasks in hand and ensuring the team knows what is expected of them.
- I will continually review the situation, asking questions of the team and giving out specific instructions when necessary.
- I will NOT be distracted from this role. If telephone calls need to be made or conversations had then I will allocate this to someone else. I believe it crucial that leadership of the situation should not change if it can be avoided.
If there is one crucial element of crisis resource management, then for me it would be COMMUNICATION. If you can maintain this then at least half the battle is won and confusion should not take over.
Simulation suites are now becoming more widespread, and they try to teach team members how to be effective in their membership and leadership of the teams in the hope that practice makes perfect. Like the performing of a pre flight checklist it is hoped that this practice will provide a mental checklist when the going gets tough.
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