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Crisis Resource Management



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

Howard S, Gaba D, Fish K, Yang G, Sarnquist F. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992;63(9):763-770. [PubMed]
Gaba D. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth. 2010;105(1):3-6. [PubMed]
Cheng A, Donoghue A, Gilfoyle E, Eppich W. Simulation-based crisis resource management training for pediatric critical care medicine: a review for instructors. Pediatr Crit Care Med. 2012;13(2):197-203. [PubMed]
Reznek M, Smith-Coggins R, Howard S, et al. Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med. 2003;10(4):386-389. [PubMed]
Carne B, Kennedy M, Gray T. Review article: Crisis resource management in emergency medicine. Emerg Med Australas. 2012;24(1):7-13. [PubMed]
Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD

Latest posts by Nikita Joshi, MD (see all)

  • Joe Lex

    See also:
    Pian-Smith MC, Simon R, Minehart RD, Podraza M, Rudolph J, Walzer T, Raemer D. Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety. Simul Healthc. 2009 Summer;4(2):84-91.

    • Michelle

      Great one, Joe. Thanks! Here’s the pubmed link:

    • njoshi8

      That Harvard sim group is just as prolific as Gaba”s Stanford group.. thanks for the great reference!

  • Fayhan Alotaiby

    Well done, I’ve enjoyed it!

    But i would suggest to put “Establish a leader” as the second step instead third one in which it would definitely has its own impact on other following steps including “Close the loop in communicating” in particular.
    thanks again for the great work and post

    • njoshi8

      Interestingly enough, no research has been put into if one CRM principle is more important than another.. in fact, I would argue that all are equally critical and must be present for a successful resuscitation. What do you think?

      • Fayhan Alotaiby

        agree! they are critically important and must be present for a successful resuscitation but my point is practically it would be more successful to establish the leadership first prior appointing tasks and closing the loop of communication among the team members. ED daily practices and experiences of successful resuscitation scenarios would support this principle and I can not make this claim as an EBM supported principle and I hope to see any data regarding this matter!
        thanks for the reply and good job again.

        • njoshi8

          Thanks Fayhan – glad to have your thoughtful input!

  • Rahul

    Well explained and demonstrated. Kudos.

    • njoshi8

      Thank you Rahul!

  • Andy Buck

    Great post Nikita, but we need to be very careful trying to transpose such an industry specific set of skills onto Emergency Medicine. CRM is a set of principles created over decades of aviation crash and near miss analysis, and applies very much to individuals who whilst possibly working together for the first time, have undergone rigorous, repeated and very standardised training and credentialling (in super-high fidelity simulators), with clear role delineation, who use highly standardised language, standard operating procedures and checklists in a system with multiple redundancies built in.

    In Australian ED’s at least, none of these characteristics apply to the majority of resuscitation situations, in which groups of strangers, most of whom have never or rarely worked together before, who represent different specialties, with different training, different levels of human factors and clinical experience, (from none to high level), and who have different priorities for the patient, congregate in a high pressure environment having never undergone interdisciplinary scenario or simulation training, in a system where there are few or no safety redundancies built in. Whilst some of the communication tips are pertinent, I think we really need to analyse our own specialty, train in simulation with our non-ED colleagues, enforce set standards of behaviour (as has been the case in operating theatres for decades), and look at defining what we really need, which is Resuscitation Room Management (RRM) skills. There is also huge cultural change that needs to happen in medicine, starting with removal of the “blame culture” that plagues our industry, and acceptance of the “error detection and avoidance” culture prevalent in many other high risk industries, before CRM or RRM can ever be effective in medicine.

    If you want to learn about the aviation CRM model, and how little of it applies to what we do in the ED, I suggest people read “Crew Resource Management” (by Kanki, Helmreich and Anca)., (available on Amazon/Kindle).

    Alternatively you can check out my blog, Resus Room Management (google it) or go to www (dot) resusroom (dot) mx where I discuss these issues, especially the aviation vs Emergency Medicine conundrum at length!

    The next post on RRM will have to be: Anaesthesia vs Emergency Medicine (as I think they need different skills to us… but that’s another rant for another time)!



    • njoshi8

      Wow thanks for the fantastic post Andy.. You bring up some great points to ponder over, and thank you for the reference to check out your postings on Resus Room Management.

      I think that simply talking about these management skills is one of the best ways to get away from blame culture, and to give people tools for how to manage difficult situations. But blaming never amounts to anything productive.

      I will definitely check out Crew Resource Management – thank you for that reference.

      I would be very very curious to see your thoughts on the differences between anesthesia and EM.. because I feel despite the change in location (OR vs ED), team work and management skills are still similar. Looking forward to reading about it!

      Thanks again for your comments!