Crisis Resource Management Course Research Articles

Emergency Crisis Resource Management course: a tool for transforming attitudes within emergency service teams

Emergency Crisis Resource Management course: a tool for transforming attitudes within emergency service teams

Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologists: A simulation-based observational study

Study objectiveIn a perioperative emergency, anesthesiologists must acknowledge the unfolding crisis promptly, call for timely assistance, and avert patient harm. We aimed to identify vital signs and qualitative factors prompting crisis acknowledgment and to compare responses between observers and participants in simulation. DesignProspective, simulation-based, observational study. SettingAn anesthesia crisis resource management course at a freestanding simulation center. SubjectsSixty attending anesthesiologists from a variety of practice settings. InterventionsIn each case, a primary anesthesiologist in charge (PAIC) managed a simulated patient undergoing a uniformly scripted sequence of perioperative anaphylaxis and called for help from another anesthesiologist when a crisis began. Anesthesiologist observers (AOs) viewed the case separately and recorded times of crisis onset. MeasurementsSimulation footage was reviewed by investigators for patient vital signs and participant behaviors at times of crisis acknowledgment, with the call for help as an explicit proxy for PAIC crisis acknowledgment. These factors were categorized, and group-level data were compared. ResultsNineteen PAICs and 41 AOs were included. Clinicians acknowledged crises around a mean arterial pressure (MAP) of 65 mmHg and oxygen saturation of 94% as anaphylactic shock progressed. PAICs acknowledged crises at a higher respiratory rate than AOs (20 vs. 18 breaths/min, p = 0.038). Other vitals and timing of crisis acknowledgment did not differ between PAICs and AOs. Nearly half of all participants (45%) identified crises at MAP <65 mmHg. Timing of crisis acknowledgment varied widely (range: 421 s). ConclusionsDespite overall heterogeneity in clinical performance, anesthesiologists acknowledged crises per standard definitions of hypotension. Thresholds for crisis acknowledgment did not significantly differ between PAICs and AOs, suggesting minimal effect from active care responsibility. Many indicated crises at MAP <65 mmHg or after significant deterioration, risking failure-to-rescue events. We suggest that crisis management instruction should address triggers for requesting help.

Filling the Gap: Simulation-based Crisis Resource Management Training for Emergency Medicine Residents.

IntroductionIn today’s team-oriented healthcare environment, high-quality patient care requires physicians to possess not only medical knowledge and technical skills but also crisis resource management (CRM) skills. In emergency medicine (EM), the high acuity and dynamic environment makes CRM skills of physicians particularly critical to healthcare team success. The Accreditation Council of Graduate Medicine Education Core Competencies that guide residency program curriculums include CRM skills; however, EM residency programs are not given specific instructions as to how to teach these skills to their trainees. This article describes a simulation-based CRM course designed specifically for novice EM residents.MethodsThe CRM course includes an introductory didactic presentation followed by a series of simulation scenarios and structured debriefs. The course is designed to use observational learning within simulation education to decrease the time and resources required for implementation. To assess the effectiveness in improving team CRM skills, two independent raters use a validated CRM global rating scale to measure the CRM skills displayed by teams of EM interns in a pretest and posttest during the course.ResultsThe CRM course improved leadership, problem solving, communication, situational awareness, teamwork, resource utilization and overall CRM skills displayed by teams of EM interns. While the improvement from pretest to posttest did not reach statistical significance for this pilot study, the large effect sizes suggest that statistical significance may be achieved with a larger sample size.ConclusionThis course can feasibly be incorporated into existing EM residency curriculums to provide EM trainees with basic CRM skills required of successful emergency physicians. We believe integrating CRM training early into existing EM education encourages continued deliberate practice, discussion, and improvement of essential CRM skills.

Crisis Resources for Emergency Workers (CREW II): results of a pilot study and simulation-based crisis resource management course for emergency medicine residents

Emergency department resuscitation requires the coordinated efforts of an interdisciplinary team. Aviation-based crisis resource management (CRM) training can improve safety and performance during complex events. We describe the development, piloting, and multilevel evaluation of "Crisis Resources for Emergency Workers" (CREW), a simulation-based CRM curriculum for emergency medicine (EM) residents. Curriculum development was informed by an a priori needs assessment survey. We constructed a 1-day course using simulated resuscitation scenarios paired with focused debriefing sessions. Attitudinal shifts regarding team behaviours were assessed using the Human Factors Attitude Survey (HFAS). A subset of 10 residents participated in standardized pre- and postcourse simulated resuscitation scenarios to quantify the effect of CREW training on our primary outcome of CRM performance. Pre/post scenarios were videotaped and scored by two blinded reviewers using a validated behavioural rating scale, the Ottawa CRM Global Rating Scale (GRS). Postcourse survey responses were highly favourable, with the majority of participants reporting that CREW training can reduce errors and improve patient safety. There was a nonsignificant trend toward improved team-based attitudes as assessed by the HFAS (p = 0.210). Postcourse performance demonstrated a similar trend toward improved scores in all categories on the Ottawa GRS (p = 0.16). EM residents find simulation-based CRM instruction to be useful, effective, and highly relevant to their practice. Trends toward improved performance and attitudes may have arisen because our study was underpowered to detect a difference. Future efforts should focus on interdisciplinary training and recruiting a larger sample size.

Speaking Across the Drapes

Organizational behavior and management fields have long realized the importance of teamwork and team-building skills, but only recently has health care training focused on these critical elements. Communication styles and strategies are a common focus of team training but have not yet been consistently applied to medicine. We sought to determine whether such communication strategies, specifically "advocacy" and "inquiry," were used de novo by medical professionals in a simulation-based teamwork and crisis resource management course. Explicit expression of a jointly managed clinical plan between providers, a strategy shown to improve patient safety, was also evaluated. Forty-four of 54 videotaped performances of an ongoing team-building skills course were viewed and analyzed for presence of advocacy and/or inquiry that related to information or a plan; inclusion criteria were participation of a nonconfederate obstetrician and an anesthesiologist. Verbal statement of a jointly managed clinical plan was also recorded. Anesthesiologists advocated information in 100% of cases and advocated their plans in 93% of cases but inquired information in 30% of cases and inquired about the obstetricians' plans in 11% of cases. Obstetricians advocated information in 73% of cases, advocated their plans in 73% of cases, inquired information in 75% of cases, and inquired about the anesthesiologists' plans in 59% of cases. An explicitly stated joint team plan was formed in 45% of cases. Anesthesiologists advocated more frequently than obstetricians, while obstetricians inquired and advocated in more balanced proportions. However, fewer than half of the teams explicitly agreed on a joint plan. Increasing awareness of communication styles, and possibly incorporating these skills into medical training, may help teams arrive more efficiently at jointly managed clinical plans in crisis situations.

Using Medical Simulation to Teach Crisis Resource Management and Decision‐Making Skills to Otolaryngology Housestaff

Develop a course to use in situ high-fidelity medical simulation (HFS) in an actual operating room (OR) to (1) teach teamwork and crisis resource management (CRM) skills simultaneously to otolaryngology and anesthesia trainees and OR nurses and (2) provide decision-making experience to ear, nose, and throat residents and OR teams in simulated high-risk, low-frequency airway emergencies. A simulation-based, in situ CRM course was developed to teach airway management and CRM in the OR. Upon completion of each course, the participants were surveyed using questions with (1-5) scale answers. The simulated clinical scenarios took place in the intensive care unit and OR at Children's Hospital Boston. The participants consisted of pediatric otolaryngology fellows, otolaryngology residents, anesthesiology residents, fellows, and certified registered nurse anesthetists as well as OR nurses. Fifty-nine individuals participated in 9 simulation-based courses given between October 2008 and May 2010. The team members participated together in 3 simulated medical crises that centered on airway and anesthesia issues. Each simulated crisis was followed by a structured debriefing session conducted by trained debriefers. Embedded within the course were didactics on CRM principles. The participants' responses on the survey included General Course Organization, Realism, Debriefing, and Relevance to Future Practice. Ninety percent of the responses were favorable or very favorable. Using a newly developed, in situ HFS-based course, clinical decision-making skills and teamwork can be effectively taught concurrently to members of an OR team.

Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment

This study was performed to assess perioperative reevaluation of Do-Not-Resuscitate (DNR) orders by practicing anesthesiologists. As part of an Anesthesia Crisis Resource Management course, an anesthesiologist interviewed a patient-actor with prostate cancer and bone metastases scheduled for a central venous catheter placement. The chart included a properly documented DNR order and the patient-actor's scripted responses emphasized that he would accept resuscitative efforts only "if the adverse clinical events were believed to be both temporary and reversible." Later, the subject assumed responsibility for the anesthesia in which the patient subsequently developed an iatrogenically induced pneumothorax, became apneic, and had a cardiovascular arrest requiring a prolonged resuscitation. Responses to these events and a following survey were evaluated. Fifty-seven percent of the subjects (17/30) addressed resuscitation during the preoperative interview; 27% (8/30) decided to suspend the DNR order and 30% (9/30) instituted a goal-directed or procedure-directed DNR order. Ninety percent (27/30) of the groups chose to continue resuscitative efforts until the simulation ended. Of the surveyed participants, over 90% would place a chest tube, intubate the trachea, do chest compressions, and perform cardiac defibrillation. Common reasons for intervening were reversibility, iatrogenicity, and that intervention would be consistent with the patient's goals. Inadequacies in perioperative reevaluation of DNR orders existed at all stages. Simulation of perioperative DNR orders is a useful way to elicit anesthesiologist's actions in the heat of the moment, which may bring us closer to understanding the actions of anesthesiologists during clinical practice.

Building a Simulation‐based Crisis Resource Management Course for Emergency Medicine, Phase 1: Results from an Interdisciplinary Needs Assessment Survey

Emergency department (ED) resuscitation requires the coordinated efforts of an interdisciplinary team. Human errors are common and have a negative impact on patient safety. Although crisis resource management (CRM) skills are utilized in other clinical domains, most emergency medicine (EM) caregivers currently receive no formal CRM training. The objectives were to compile and compare attitudes toward CRM training among EM staff physicians, nurses, and residents at two Canadian academic teaching hospitals. Emergency physicians (EPs), residents, and nurses were asked to complete a Web survey that included Likert scales and short answer questions. Focus groups and pilot testing were used to inform survey development. Thematic content analysis was performed on the qualitative data set and compared to quantitative results. The response rate was 75.7% (N = 84). There was strong consensus regarding the importance of core CRM principles (i.e., effective communication, team leadership, resource utilization, problem-solving, situational awareness) in ED resuscitation. Problems with coordinating team actions (58.8%), communication (69.6%), and establishing priorities (41.3%) were among factors implicated in adverse events. Interdisciplinary collaboration (95.1%), efficiency of patient care (83.9%), and decreased medical error (82.6%) were proposed benefits of CRM training. Communication between disciplines is a barrier to effective ED resuscitation for 94.4% of nurses and 59.7% of EPs (p = 0.008). Residents reported a lack of exposure to (64.3%), yet had interest in (96.4%) formal CRM education using human patient simulation. Nurses rate communication as a barrier to teamwork more frequently than physicians. EM residents are keen to learn CRM skills. An opportunity exists to create a novel interdisciplinary CRM curriculum to improve EM team performance and mitigate human error.

A Method for Measuring the Effectiveness of Simulation-Based Team Training for Improving Communication Skills

Team behavior and coordination, particularly communication or team information-sharing, are critical for optimizing team performance; research in medicine generally provides no accepted method for measurement of team information-sharing. In a controlled simulator setting, we developed a technique for placing clinical information (probes) with members of a team of trainees participating in a 1-day Anesthesia Crisis Resource Management course and later tested the teams for knowledge of the probes as an indicator of overall team information-sharing. Despite the low level of team information-sharing, we demonstrated construct validity of the probe methodology by the correlation of measured change in team information-sharing from beginning to end of training with self-rated change. There was no statistical difference in "group sharing" from beginning to end of training, despite trainees' survey responses that the course would be useful for their education and practice.

Assessment of resident professionalism using high-fidelity simulation of ethical dilemmas.

To examine the responses of emergency medicine residents (EMRs) to ethical dilemmas in high-fidelity patient simulations as a means of assessing resident professionalism. This cross-sectional observational study included all EMRs at a three-year training program. Subjects were excluded if they were unable or unwilling to participate. Each resident subject participated in a simulated critical patient encounter during an Emergency Medicine Crisis Resource Management course. An ethical dilemma was introduced before the end of each simulated encounter. Resident responses to that dilemma were compared with a professional performance checklist evaluation. Multi-response permutation procedure analysis was used to compare performance measures between resident classes, with the a priori hypothesis that mean performance should increase as experience increases. Of the 30 potential subjects, 90% (27) participated. The remaining three residents were unavailable due to scheduling conflicts. It was observed that senior residents (second and third year) performed more checklist items than did first-year residents (p < 0.028 for each senior class). Omnibus comparison of mean critical actions completed across all three years was not statistically significant (p < 0.13). Residents performed a critical action with 100% uniformity across training years in only one ethical scenario ("Practicing Procedures on the Recently Dead"). Residents performed the fewest critical actions and overall checklist items for the "Patient Confidentiality" case. Senior residents had better overall performance than incoming interns, suggesting that professional behaviors are learned through some facet of residency training. Although limited by small sample size, the application of this performance-assessment tool showed the ability to discriminate between experienced and inexperienced EMRs with respect to a variety of aspects of professional competency. These findings suggest a need for improved resident education in areas of professionalism and ethics.

Crisis resource management training for an anaesthesia faculty: a new approach to continuing education.

Human error and system failures continue to play a substantial role in adverse outcomes in health care. Anaesthesia crisis resource management addresses many patient safety issues by teaching behavioural skills for critical events but it has not been systematically utilized to teach experienced faculty. An anaesthesia crisis resource management course was created for the faculty of our medical school's anaesthesia teaching programmes. The course objectives were to understand and improve participants' proficiency in crisis resource management (CRM) skills and to learn skills for debriefing residents after critical events. Through surveys, measurement objectives assessed acceptance, utility and need for recurrent training immediately post-course. These were measured again approximately 1 year later along with self-perceived changes in the management of difficult or critical events. The highly rated course was well received in terms of overall course quality, realism, debriefings and didactic presentation. Course usefulness, CRM principles, debriefing skills and communication were highly rated immediately post-course and 1 year later. Approximately half of the faculty staff reported a difficult or critical event following the course; of nine self-reported CRM performance criteria surveyed all claimed improvement in their CRM non-technical skills. A unique and highly rated anaesthesia faculty course was created; participation made the faculty staff eligible for malpractice premium reductions. Self-reported CRM behaviours in participants' most significant difficult or critical events indicated an improvement in performance. These data provide indirect evidence supporting the contention that this type of training should be more widely promoted, although more definitive measures of improved outcomes are needed.

Do anaesthesiologists feel alone in the operating room?

SANTANDER-02-12 Anaesthetists work in dynamic and complex environments. Teamwork is required and team error can be defined as action or inaction leading to deviation from team or organizational intentions [1]. Effective teamwork is an error-management technique, and communication also has several positive side effects, such as fewer and shorter delays, and increases efficiency [2]. Leadership is an essential ingredient of success in the search for safety, as it is throughout the enterprise of quality [3]. The aim of this study is to assess anaesthesiologists' self-perception regarding their teamwork and team organization. We show preliminary data of a projected broader study. Methods and Results: 14 staff anaesthesiologists who attended an Anaesthesia Crisis Resource Management course at Santander Simulation Centre were surveyed before and after the course (Tables 1 and 2) to study their self-perception regarding teamwork and team organization.Table 1: Pre-course survey results.Table 2: Post-course survey results.Conclusions: The anaesthesiologists surveyed have a poor self-perception about team organization and teamwork during their job. Anaesthesiologists have developed a deficient skill in communication. Simulator training may improve the patient safety by emphasizing the significance of team organization and enhancing communication among the team. From their written and verbal comments, most believed they learned a great deal about teamwork. Because these results are subjective thoughts, it would be necessary to develop an objective measurement instrument, which avoids some of the limitations of traditional approaches to measuring teamwork attributes. It is desirable that simulator training involves complete operating room teams to achieve improved performance [4].

Leadership Training: A New Application of Crisis Resource Management and Distance Education in a Large Group Format at a Medical Simulation Facility

Leadership and teamwork skills must be practiced to gain full value from a leadership course. The leadership role is one of the main points highlighted during a Crisis Resource Management (CRM) session. While a typical CRM session offered in a medical simulation laboratory uses a medical crisis to elicit behaviors for videotaping and debriefing, the CRM principles are generic and applicable to leadership training outside medical practice. The Simulation Development and Cognitive Science Laboratory of the Pennsylvania State University College of Medicine offered a CRM course to high school students using a pediatric full human simulator (M.E.T.I.) The students rotated through two sessions: as hands-on participants in the Simulation Laboratory, and in a remote education mode. During the remote session, they viewed their peers via a video link, discussed the crisis and were able to assist their peers. The 17 students valued the overall session at a high level (4.9 ± 0.2 on a five-point scale; mean ± SD). The majority of students (n=10) indicated that they felt involved in both the hands-on and remote sessions (≥7 on a ten-point scale). Based on the results, all participants believed the session was of great value and that they could use CRM principles in everyday situations. We believe that the participants found significant value in the CRM session as a leadership skills resource. Most students also felt involved in the remote sessions, thereby enabling a larger group of trainees to learn about and experience CRM principles.

4 Anaesthesia simulators

The practice of anaesthesia involves routine activities which have the potential to develop into critical incidents. Moreover, many life-threatening complications in anaesthesia are so rare that practitioners seldom, if ever, come across them in routine practice. In this respect, anaesthesia is comparable to industries such as aviation and the nuclear power industry. Simulators and training devices are regularly used in these industries to maintain the efficiency and proficiency of operators. Within the past few years, there has been an increasing interest in the use of simulators in anaesthesia. Many computer screen-based and full-scale anaesthesia simulators have been developed and evaluated. The computer screen-based simulators are less expensive and more widely available. However, they lack the ability to simulate reality and certain other aspects of anaesthesia such as the human-machine and interpersonal interactions. Full-scale simulators recreate the whole anaesthesia work environment, but the disadvantage of these simulators is their high acquisition and running cost. The major purpose of anaesthesia simulators is to rehearse the management of both frequently occurring and rare events during anaesthesia. Full-scale anaesthesia simulators are ideal for training anaesthetists about the concepts of human-machine interactions and the complications of working in a complex environment. Many simulator-based training courses, which involve these concepts, have been developed and are being conducted in many training centres (e.g. the Anaesthesia Crisis Resource Management course and, the Rational Anaesthesia course). Simulators are also useful for continuing education of practising anaesthetists. Routine in-training examinations, assessment of trainees with questionable competence and periodic re-examination of practitioners could be conducted on simulators. As research tools, simulators can be used to study the responses of anaesthesia personnel to critical incidents, the utility of different displays and alarm modalities, the effects of artifacts or false alarms on problem-solving performance, and the effect of fatigue and other stresses on anaesthetists' performance. In addition, anaesthesia simulators can be used to evaluate the ergonomics and performance of equipment, especially during the development phase. Interest in anaesthesia simulators is increasing rapidly and the devices are constantly being improved. However, the full potential of these devices in the practice of anaesthesia needs to be explored further.