CRM Guidelines
Crisis Resource Management (CRM) for ECLS Education
- CRM refers to the non-technical skills required for effective teamwork in a crisis situation
- 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 ED, trauma teams and MET teams)
FACTORS AFFECTING THE PERFORMANCE OF COMPLEX TASKS
Individual (e.g. HALTS – hungry, angry, late, tired or stressed)
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- Fatigue
- Sleep deprivation
- Emotional disturbance (e.g. angry, stressed)
- Ill health
- Inexperience
- Lack of knowledge
Team
- Role confusion
- High power distance/ authority gradient
- Ineffective communication techniques
Environment
- Interruptions
- Noise
- Handovers
- Production pressure
- Equipment failure
- Unfamiliar place and equipment
KEY PRINCIPLES OF CRM
The way key principles are organised in this document is as follows:
- Know your environment
- Anticipate, share and review the plan
- Ensure leadership, role clarity and good teamwork
- Communicate effectively
- Call for help early
- Allocate attention wisely – avoid fixation
- Distribute the workload – monitor and support team members
Rall and Gaba have identified the followed 15 key principles, but some these can be nested within the above key principles:
- Know the environment
- Anticipate and plan
- Call for help early
- Exercise leadership and followership
- Distribute the workload
- Mobilize all available resources
- Communicate effectively
- Use all available information
- Prevent and manage fixation errors
- Cross (double) check
- Use cognitive aids
- Re-evaluate repeatedly
- Use good teamwork
- Allocate attention wisely
- Set priorities dynamically
KNOW YOUR ENVIRONMENT
Environment
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- Know location and function of equipment, especially for time-critical procedures
- Logically structured and 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 ED resus room setting)
ANTICIPATE, SHARE AND REVIEW THE PLAN
Plan
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- Think ahead and plan for all contingencies
- Set priorities dynamically
- Re-evaluate periodically
- Anticipate delays
- Use 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
ENSURE LEADERSHIP, ROLE CLARITY AND GOOD TEAMWORK
Leadership
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- Employ the least confrontational approach consistent with the goal
- Participative decision making improves team buy in
- Use an authoritative approach when necessary (e.g. time critical situations)
- Allocate team roles
- 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
- Team members should show good followership and be active – each observes and monitors events and advocates or asserts corrective actions
- Leader provides debriefing
- 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
Communication
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- 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
CALL FOR HELP EARLY
Help
-
- 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
Avoid Fixation
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- 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
DISTRIBUTE THE WORKLOAD – MONITOR AND SUPPORT TEAM MEMBERS
Team Members
- Team Leader 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