Crisis Resource Management (CRM) for ECLS Education

OVERVIEW

• 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)

• • 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:

1. 1. Know the environment
   2. Anticipate and plan
   3. Call for help early
   4. Exercise leadership and followership
   5. Distribute the workload
   6. Mobilize 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

  KNOW YOUR ENVIRONMENT

• • 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

• • 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

• • 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

• • 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

• • 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

  DISTRIBUTE THE WORKLOAD – MONITOR AND SUPPORT 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