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?