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CRM and SBT… just another set of acronyms in the world of medical education?  Don’t we already have enough??

Not quite!  Rather, Crisis Resource Management (CRM) is a complementary approach to Simulation Based Training (SBT). It can enhance current ongoing medical simulations or provide foundation for a vigorous curriculum when launching new simulation programs.

What is it?

Crisis Resource Management is the ability to translate medical knowledge to real world actions, in the setting of an emergency. [1]

Rather than a separate entity from medical simulation, CRM principles can be looked at as a way to focus and shape medical simulation curriculum and especially the objectives of each case to focus upon development of critical skill-sets that contribute to optimal team function and success during crisis.

Below is a great video by Dr. Christopher Gallagher from Stony Brook Simulation Center that describes CRM. He has identified 5 critical CRM principles and shows their application in a simulation setting. 

  1. Recognize this is serious and call for help.
  2. Close the loop in communicating.
  3. Establish a leader.
  4. Use resources appropriately.
  5. Step back and do a global assessment.

Crew Resource Management

CRM was a training paradigm, originally known as Crew Resource Management, which was created by the aviation industry, NASA, and US military to address deficiencies in aviation training in the 1970’s. It came from a time when 70% of airline crashes were due to human error. Vigorous research discovered core behaviors such as failure to plan and fixation error that were inherent and contributory to negative outcomes. From this came the original educational curriculum known as CRM that changed the industry.

In the late 1980’s Anesthesiologist Dr. David Gaba and his group at Stanford began to examine Crew Resource Management and discovered applications in the anesthesia field via medical simulation. Both the aviation and medical fields are high stress, require time-sensitive decision making under pressure. Many of David Gaba’s publications describe the application of CRM from aviation industry into an Anesthesia core curriculum simulation training that he launched in 1990. [2].

Principles of CRM

CRM skills consists of the following abilities to help translate knowledge into effective action in a crisis situation (Rall M, Gaba D Human Performance and Patient Safety, Miller 6th Ed. 2005)

  • Know your environment
  • Anticipate and plan
  • Call for help early
  • Ensure leadership and followership
  • Distribute the workload
  • Mobilize all available resources
  • Communicate effectively
  • Use all available information
  • Prevent and manage fixation errors
  • Cross (double) check
  • Use cognitive aids
  • Re-evaluate repeatedly
  • Use good teamwork
  • Allocate attention wisely
  • Set priorities dynamically

How does CRM work?

  • Provides structure of how a leader will lead
  • Guides team members how they should contribute and participate
  • Develops shared mental models that allow for streamlined resuscitations
  • Teaches how to communicate efficiently and honestly

These nontechnical CRM skills, when learned in conjunction with medical and technical skills, can significantly reduce clinical error and improve medical resuscitations.  [3]

How to effectively use CRM and Simulation Together

Simulation allows for structured and systematic teaching of the CRM principles through established curriculum and set objectives. It may even be best to organize high fidelity simulation objectives around CRM principles, in addition to medical knowledge and procedural skills. Debriefing can focus upon the CRM principles which would drive the conversation. Through the use of common vocabulary, the learners will become familiar with the concepts of CRM and can more easily apply them during a real critical situation. [4] [5] 

Further Reading

Crisis Management in Acute Care Settings: Human Factors, Team Psychology, and Patient Safety in High Stakes Environment – Michael St. Pierre, Gesine Hofinger, Cornelius Buerschaper, Robert Simon, Springer, Heidelberg, 2011. Amazon link

 

Image 1

References

  1. S.K. Howard, D.M. Gaba, K.J. Fish, G. Yang, and F.H. Sarnquist, "Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents.", Aviation, space, and environmental medicine, 1992. http://www.ncbi.nlm.nih.gov/pubmed/1524531 
  2. D.M. Gaba, "Crisis resource management and teamwork training in anaesthesia.", British journal of anaesthesia, 2010. http://www.ncbi.nlm.nih.gov/pubmed/20551023 
  3. A. Cheng, A. Donoghue, E. Gilfoyle, and W. Eppich, "Simulation-based crisis resource management training for pediatric critical care medicine: a review for instructors.", Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2012. http://www.ncbi.nlm.nih.gov/pubmed/21499181
  4. B. Carne, M. Kennedy, and T. Gray, "Review article: Crisis resource management in emergency medicine.", Emergency medicine Australasia : EMA, 2011. http://www.ncbi.nlm.nih.gov/pubmed/22313554
  5. M. Reznek, R. Smith-Coggins, S. Howard, K. Kiran, P. Harter, Y. Sowb, D. Gaba, and T. Krummel, "Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2003. http://www.ncbi.nlm.nih.gov/pubmed/12670855 
Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Associate Editor
Editorial Board Member
ALiEM-CORD Fellowship Director
ALiEM-EMRA Fellowship Director
Clinical Instructor
Stanford University, Division of Emergency Medicine