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Why CRM should’t be used in Emergency Medicine – Part 1

Crisis In The Cockpit

The aviation model of CRM, whilst tempting to adopt, is an industry specific set of skills and practices that has evolved over several decades, and is based on analysis of hundreds of airplane crashes, accidents and near-misses. To try and drag the concepts of CRM across and overlay them onto an entirely different industry is illogical.  Emergency Department Resuscitation needs it’s own set of skills, derived from what we do at work every day, and CRM does not meet this need.

The “C” in CRM stands for Crew, Cockpit, or Crisis, depending on who you ask.  “Crew” from an aviation perspective means a pre-determined number of people, each with clear cut roles, responsibilities, and skill levels.  ED resuscitations are characterised by variable and differing group sizes and skill mixes, so at the start, “crew” is an inappropriate term. Cockpits again, are designed for a set number of people, each able to carry out a pre-determined set of job specific tasks based on their position in the cockpit.  Resus rooms are dynamic open spaces, with the only absolute task that must be performed from one place in that room being airway management (specifically intubation) – everyone else is free to roam about, and may in fact need to move to accomplish their tasks. Cockpits do vary with the make of the aircraft, however pilots are not allowed to fly a new aircraft without previously having been specifically oriented to that cockpit and undergone specific training to familiarise themselves with that space.  Our apprenticeship model means that most doctors are never formally oriented to, or trained in a resus room, but gain experience by gradual exposure over many years, and by doing medical short courses, without any formal training or certification.  And “Crisis”.  Do you want to even think of your resus room as place where crises happen? I don’t.

So just based on the terminology alone, CRM is an inappropriate phrase to use in the setting of Emergency Department resuscitation.

No universally applicable, formal model of review, quality assurance or incident critique exists in the medical world.  Incident reporting systems (for example the dreaded “RiskMan” used in Australian hospitals) are rarely if ever used by medical staff.  In my nearly 15 years of work in the public health system I have never been shown how to complete a computer based incident report, nor have I ever completed one, despite having been witness to countless reportable incidents. They are seen as cumbersome and time consuming, with many irrelevant questions, and once sent into the ether of hospital bureaucracy, it is hard to see a tangible result.

One of the main stumbling blocks for establishing real-time monitoring and review of resuscitation is patient confidentiality, which precludes filming or recording of patients, (as opposed to black box flight recorders) and therefore prevents accurate quality assurance and review processes. If hospitals would allow the filming of resuscitation for quality assurance purposes, and there were clear guidelines for the analysis of this footage, adequate data-security measures as well as constructive feedback processes, it may be possible to have a real impact on error rates in resus.

Some of the general CRM concepts such as “fixation”, “graded assertiveness” and “situational awareness” seem at face value to have some relevance to medical situations, however they are concepts, not skills.  As mentioned, Emergency Department medical and nursing staff, and other visiting non-ED specialties who come to assist in resus need their own set of job specific skills that can be utilised in resus settings.  Copying and extrapolating from an entirely different industry is not the way to achieve this.

What job-specific tasks do you think ED and visiting non-ED medical staff need to function in resus?

 

6 Responses to Why CRM should’t be used in Emergency Medicine – Part 1

  1. Scott Orman December 30, 2012 at 11:38 pm #

    Hi Andy

    What a superb idea for a site – I think the concept of RRM instead of CRM is fantastic.

    I still think CRM has a lot to teach us though. You are absolutely right that superimposing a system from aviation directly onto emergency medicine is illogical… but this is more about specifics than concepts, and the concepts are much more important in patient care.

    While training for prehospital care, I was lucky enough to have the opportunity to attend a purely aviation CRM course. The concepts from that, (which in my opinion) are equally applicable to emergency medicine, are:

    -in times of stress humans can perform poorly and exercise poor judgement
    -some tasks require so much concentration and focus that it is impossible to maintain overall awareness of a situation
    -hierarchies are a barrier to junior people speaking up when they have an idea to contribute or see an impending hazard

    A number of aviation disasters (including aeromedical ones!) were presented, and the most common themes included failures to recognize/deal with the three points above rather than aviation-specific problems.

    If you asked me to define ‘CRM’ for ED I would struggle to produce a working definition, but the concepts involved and the language used for me have provided a mental framework on which to hang all the stuff I have picked in in resus over the years (some by intuition, some by doing things the right way, some by doing things the wrong way!)

    Pulling out the useful elements from CRM, discarding the rest, and building ‘RRM’ though is a logical next step – fantastic idea, and good luck with your site!

  2. Nikita Joshi December 31, 2012 at 12:42 am #

    Great write up! What do you think of Teamstepps as a model for working resuscitation in the ED?

  3. Andy Buck December 31, 2012 at 9:59 am #

    Thanks Scott & Nikita

    Scott – I do agree that some of the factors that lead to humans making errors are universal (see Cliff’s post about his kids swimming instructor!), however I am wary of such an industry specific concept being transposed to “medicine”, without analysis of the specifics of the working environment of each specialty. The factors at play for Anaesthetists, Surgeons, Pre-hospitalists and Emergency Physicians are all different. What I’m hoping to build into RRM is the ED specifics that affect error and job-specific tasks that can prevent or manage these errors. I think you’ve distilled the main concepts, and a short list like that of the general concepts is useful for background information for ED people. Thanks for your insightful input!

    Nikita
    I think TeamSTEPPS is an excellent concept, and if you can manage to convince your hospital to implement their program, then I’m sure it would be beneficial. I think one of the good things about the model is the “train the trainer” component, which means that new staff can be be trained, meaning that rotating staff will be able to pick it up (in theory). The downside is, (as we who work in the public health system in Australia know all too well), that implementing change in such bureaucratic organisations as public hospitals, is very, very slow, requires groups of motivated individuals to drive the project, and there are numerous barriers to overcome. Looking at the Victorian Department of Health website, they have done a pilot TeamSTEPPS program in a single ward in 5 different hospitals, and it has taken 2 years to complete phase 1. This is astoundingly slow. So in summary, great concept at an organisational level, but it’s quite cumbersome to implement. Thanks very much for the comment, and I’ll keep an eye on the TeamSTEPPS program, as it looks like its gaining popularity in Australia.

  4. Chris Nickson (@precordialthump) January 1, 2013 at 5:59 pm #

    Looking forward to following the new blog Andy.

    I’m still not convinced that Crisis Resource Management is such a bad term – crisis simply means a time of danger or a time for important decisions. Similar scenarios happen in ICU, MET calls, retrieval, rural clinics and in the ED among other locations. The similarities are greater than the differences. Even in aviation they often have co-pilots have haven’t flown together before (at least in the millions of episodes of Air Crash Investigation I have seen!). The concepts of human factors, latent errors, etc etc are universal to complex systems that humans play a role in.

    Nevertheless I look forward to seeing how your approach to resus room management developments, focusing on the specific issues faced in the ED resus room. It’s an under-emphasized area of EM practice in my opinion, which is bizarre, because why else does anyone do emergency, if not to “own the resus room”?

    Chris

    • Andy Buck January 1, 2013 at 10:39 pm #

      Thanks Chris
      Fair comment about the use of “crisis” to mean a high risk situation, however I think it has negative connotations that are best left out of a resus environment. Whilst resus in ICU, MET calls, retrieval, rural clinics and the ED have some similarities, I still think that there are specifics to each environment that need to be clarified, defined, trialled and critiqued to find the optimal job specific skills for each. I’d argue that the actual skills required to manage resus of a fasted, elective, surgical patient, whose past history is known, who’s been to pre-admission, whose co-morbities, medications, allergies, airway anatomy and prior physical condition are known, who deteriorates on the table in theatre, with the resus managed by a single anaesthetist (or a few anaesthetists) and a small group of theatre staff are actually quite different from the skills required to manage an unknown patient, with limited or no information about past history, with a highly variable and unpredicable set of staff with highly variable skills in a busy ED whilst simulatenosuly dealing with interruption, family members, non-ED medical staff, ancillary staff (eg radiographers, paramedics, police) and the constant nag of patient flow and KPI’s. That’s what I want to tease out with this project. I want to at least get people talking, to start to establish a set of skills specific to ED Resus, so that we can start defining what is optimal for our environment.

      Regarding use of the term “CRM” in medical (in particular ED) situations, my main gripe is the aviation association, and the current attempts to apply concepts developed in a strikingly different industry to medical situations. Yes there are some common theoretical connections related to the causes of human error, but the application of these concepts and the job specific tasks that we need in ED to apply these concepts are yet to be defined, and as will be demonstrated in an upcoming post, the differences between aviation and medicine are actually quite striking (and I’ll specifically address the issue of how airline pilots who haven’t flown together before manage to function safely together).

      Thanks again for the insightful comments.

  5. Capt. Gary Guyot December 31, 2014 at 5:26 am #

    I think you may be misinterpreting what CRM is.
    CRM is about teamwork. CRM has not changed Aviators use of checklists and practiced emergency procedures.

    CRM is not about training people to act to a set of procedures pre-determined to be a requirement. Which seems to me to be your problem with using it in an ED setting.
    I have been an aircraft captain for 20 years and witnessed the implementation of CRM in Aviation. I am not a medical professional so please excuse any incorrect assumptions that I may make.

    I think you are worried about a situation where the Dr. is being hindered by a loss of authority in the ED room. Old timers in the cockpit had the same problem. I saw it first hand in class. They resisted it as a nuisance change as well. Comments like “In an emergency, I won’t have time to ask for the co-pilot’s permission to do something”.
    In aviation they teach us the ancillary concepts noted by other commenters in this thread. Such as fixation and overload. This is just to gives more understanding of why we use CRM.
    It takes a certain amount of ego to put peoples lives in our hands on a routine basis. This personality trait can be lethal but it really is required to do our jobs. So aviation came up with a way of thinking rather than a way to conduct ours jobs.
    Real CRM means that the 10,000 hour airplane captain takes an operational comment from even the building’s janitor seriously. (The janitor can see a fluid puddle under a plane as well as anyone). Real CRM means that you use every tool available to you, human or procedural.
    The majority of in flight emergencies I have been involved with have not followed a predictable progression. Which I am sure is just about every ED situation. Such situations usually follow a general theme that can be trained but never a specific one that takes personal skill. In most in-flight situations, we (the crew) acted outside the box to the best of both of our abilities in a synergistic way. The synergy came from our open and professional communication that we gained from applying CRM principles.
    You may be worried about Bureaucracy slowing you down or losing your authority. CRM does not create these problems, is solves them in any team/stress situation.
    All of the things you are worried about, such as checklists and training ED crews and assigning specific jobs that limit the use of people’s skills is a organizational thing.
    If your group actually embraced CRM, it would mean that you could go to your chain of command and eliminate or modify issues you face in the ED room.

    Summery. Don’t compare CRM in Aviation to CRM in medical by the environments that they exist in. CRM in ICU would be different than CRM in the ED room as well. You can use CRM to come up with the best culture of conduct in the ED room.
    To save the most people.
    I noticed that you sell a course based on PRM. PRM appears to be CRM. So please don’t downplay CRM and then turn around and teach it anyways with a different name. PRM seems to embrace using all tools and resources available to run a better ED room. Although if that’s what it takes to get your peers to use CRM then so be it.

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