CRM Guidelines

Crisis Resource Management (CRM) for ECLS Education

  • CRM refers to the non-technical skills required for effective teamwork in a crisis situation
  • Numerous factors affect the performance of complex tasks at the level of the individual, team and the environment
  • CRM originated with Crew (or ‘Cockpit’) Resource Management training developed by the aviation industry in the 1970s following the realisation that 70% of airline crashes were due to human error resulting from teamwork failure
  • CRM training improves performance and reduces errors (settings include ED, trauma teams and MET teams)

Factors affecting the Performance of Complex Tasks

Individual

Team

Environment

  • Fatigue
  • Sleep deprivation
  • Emotional disturbance (e.g. angry, stressed)
  • Health Issues
  • Inexperience
  • Lack of knowledge
    • Role confusion
    • High power distance/ authority gradient
    • Ineffective communication techniques
    • Interruptions
    • Noise
    • Handovers
    • Production pressure
    • Equipment failure
    • Unfamiliar place and equipment

Key Principles of CRM

The way key principles are organised in this document is as follows:

Rall and Gaba have identified the followed 15 key principles, but some these can be nested within the above key principles:

  • Know your environment
  • Anticipate, share and review the plan
  • Ensure leadership, role clarity and good teamwork
  • Communicate effectively
  • Call for help early
  • Allocate attention wisely – avoid fixation
  • Distribute the workload – monitor and support team members
  • Know the environment
  • Anticipate and plan
  • Call for help early
  • Exercise 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

Know your Environment

Environment

  • Know location and function of equipment, especially for time-critical procedures
  • Logically structured and well labelled environment
  • Use cognitive aids e.g. equipment maps
  • Regular training
  • Know the role and level of experience of team members (role confusion is common in the ED resus room setting)

Anticipate, Share and Review the Plan

Plan

  • Think ahead and plan for all contingencies
  • Set priorities dynamically
  • Re-evaluate periodically
  • Anticipate delays
  • Use checklists
  • Share the plan with others – sharing the mental model facilitates effective action towards a common goal
  • Think out loud and provide periodic briefings to verbalise priorities, goals and clinical findings as they change
  • Encourage team members to share relevant thoughts and plans
  • Continually review the plan based on observations and response to treatment

Ensure Leadership, Role clarity and good Teamwork

Leadership

  • Employ the least confrontational approach consistent with the goal
  • Participative decision making improves team buy in
  • Use an authoritative approach when necessary (e.g. time critical situations)
  • Allocate team roles
  • Establish behavioural and performance expectations of team members
  • Establish and maintain the team’s shared mental model of what is happening and the team’s goals
  • Monitor the external and internal environments of the team to avoid being caught off guard
  • Team members should show good followership and be active – each observes and monitors events and advocates or asserts corrective actions
  • Leader provides debriefing
  • Team members including the Leader need to be able to recognise when they are affected by stress, and develop appropriate self-care behaviours
  • All team members – Leaders and Followers – are equally responsible for ensuring good patient outcomes

Communicate effectively

Communication

  • distribute needed information to team members and update the shared mental model
  • Use closed loop communication
  • Be assertive, not aggressive or submissive
  • Avoid personal attacks
  • Resolve conflict
  • Maintain relationships
  • Facilitate collaborative efforts working towards a common goal
  • Cross (double) check

Call for Help early

Help

  • Be aware of barriers to asking for help (e.g. fear of criticism or losing face)
  • Set predefined criteria for asking for help
  • Call for help early
  • Mobilize all available resources

Allocate Attention wisely

Avoid Fixation

  • Be aware of ‘fixation error’ that reduces situational awareness
  • Prioritize tasks and focus on the most important task at hand
  • Delegate tasks to others
  • Use all available information

Distribute the workload – Monitor and Support Team Members

Avoid Fixation

  • Team Leader stands back whenever possible to maintain situational awareness and oversee the team
  • Assign tasks according to the defined roles of the team
  • Team Leader supports team members in their tasks