Crisis Resource Management: Before the Emergency
Emergencies in the operating room are frequently associated with an uncertain diagnosis and limited access to diagnostic interventions and are managed by members of a multidisciplinary team. Inefficient teamwork and errors in decision making can rapidly exacerbate the situation and possibly lead to fatal errors.
Crisis resource management (CRM) focuses on development of nontechnical skills such as decision making, interpersonal behavior, and team training in order to facilitate effective teamwork in a crisis situation. Crisis resource management aims to improve performance and decrease errors of complex tasks at the individual and team levels.
The guiding principle of CRM is that during a crisis, medical knowledge is required but not sufficient for a successful outcome. Management of the complex interactions among the environment, equipment, and different care teams is essential to function effectively in a crisis situation. These principles (Box 1.1) include an understanding of the roles of leaders and team members; rapid, effective communication; situational awareness; and knowledge of available ancillary resources.
From Murray WB. Crisis resource management among strangers: principles of organizing a multidisciplinary group for crisis resource management. J Clin Anesthesiol. 2000; 12(8): 634.
In a crisis, the leader does not become involved in any physical tasks, but instead takes a step back to get the big picture by assimilating information from team members, organizes it, and delegates the appropriate responsibility. The leader is often the first person to arrive at the scene, but may later be replaced by the person who knows the most about the patient. The leadership role may be transferred between providers if, for example, the patient’s primary physician arrives or the team leader has expertise that is required (e.g., airway management).
Team members are responsible for completing tasks assigned by the team leader. All communication between team members should go through the team leader, as should any updates or insights into management of the crisis. This will allow the leader to coordinate the activities of everyone involved in the event and maximize team awareness.
Effective communication is vital to successful crisis management. Not all providers may be familiar with each other, so introductions between team members may be beneficial if time permits. Introductions should include not only the person’s name, but also his or her role in patient management. For example, “My name is Yili Huang; I am an anesthesiologist.” Closed loop communication involves repeating back instructions. If, for example, the team leader instructs Dr. Huang to manage the airway, he should then reply, “I’ll manage the airway.” This lets the leader know that his instructions have been heard and understood, and also allows him or her to correct an erroneous instruction. Maintaining eye contact while addressing other team members directly and employing nonjudgmental comments all help make communication effective during a crisis.
Constant assessment of the crisis situation is an important part of CRM. Leaders should repeatedly take a step back to analyze the big picture. Verbal review of the situation is also important to help provide a shared mental model for the team. This helps prevent fixation errors and allow critique of the management plan when appropriate. Throughout the event, the team should prepare for anticipated needs by constantly reviewing available resources and fully utilizing them. Any member of the team can request assistance if necessary, and one of the responsibilities of the team leader is to continually be aware of what help is available and what type of support should be summoned.
Checklists have become a vital part of CRM, and have been shown to aid performance in rare and unpredictable crises. Checklists are beneficial because the stress during crisis can impede the team’s ability to recall critical steps in management. Checklists provide relevant, vital information packaged in a visually striking presentation that can be quickly and easily accessed. Checklists have been shown to improve teamwork, standardization, and performance during simulated critical events in the operating room. The current book is in reality a series of checklists for emergency situations. Therefore, this book could be used as a cognitive aid in crisis scenarios.
Box 1.2 includes three of the most accessible and validated checklists currently available.
Both initial and recurrent training are important and critical to successful CRM because of the diverse background of the operating room team. The goal is to ensure that the team functions as a unit during critical events. No matter the type of training, the team needs to adopt a willingness to cooperate toward the common goal of patient health and safety.
Petrosoniak and colleagues proposed the “triple threat” framework in a recent publication (Box 1.3). The triple threat encourages the creation of a shared mental model in which team members can train to anticipate each others’ actions by understanding each others’ perspectives and needs. Stress inoculation training identifies that stress impairs team performance, and effective management of this stress can allow for improved team function. Last, it recognizes that time pressures and the demand for high-stakes decisions promote cognitive errors, and it is necessary to learn the techniques of metacognition and thereby improve decision making.
From Petrosoniak A, Hicks CM. Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Curr Opin Anesthesiol. 2013; 26: 699–706.
Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anesthesiol. 2010; 105(1): 3–6.Find this resource:
Murray WB. Crisis resource management among strangers: principles of organizing a multidisciplinary group for crisis resource management. J Clin Anesthesiol. 2000; 12(8): 634.Find this resource:
Petrosoniak A, Hicks CM. Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Curr Opin Anesthesiol. 2013; 26: 699–706.Find this resource: