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The History of Crew Resource Management (CRM)

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Crew Resource Management training can trace its origin back to a workshop held in the United States in 1979. The National Aeronautics and Space Administration (NASA) sponsored this workshop, it was known as “Resource Management of the Flightdeck” [1]

The conference was the culmination of NASA research into the causes of air transport accidents [1]. The research findings presented during the workshop identified and drew attention to the human error aspects in a majority of air crashes as, “failures of interpersonal communications, decision making and leadership” [1]. The initial moniker applied to this concept was “Cockpit Resource Management” and encompassed the process of training crews to reduce “pilot error” by making better use of the human resources on the flightdeck [1]. Many of the air carriers represented at the workshop left it committed to the development of new training programs that would enhance the interpersonal aspects of flight operations and since that time CRM training programs have flourished not only in the United States, but also around the world. Additionally, approaches to CRM have also evolved in the years since the NASA workshop [1]. The evolution of Crew Resource Management was made possible by the aviation industry’s continued and extensive research on the subjects of human error and decision-making. The analysis of airline disasters has discovered and confirmed that, “certain skills necessary for optimal navigation through complex and rapidly evolving situations were not being taught in traditional aviation training” [2]. Following the success of CRM in aviation, it wasn’t long before a parallel was drawn between the working environments of aviation and the medical specialty of anesthesia. In the late 1980’s, anesthesiologists at the VA Palo Alto Health Care System and Stanford University developed a high-fidelity patient simulator. The principles of CRM were adapted to the practice of anesthesia leading to a simulation-based course called ‘Anesthesia Crisis Resource Management’ or ACRM. This course has now become a standard course at several U.S residency programs as well as multiple simulation centres around the globe [2].  This eventually led to the introduction of the “checklist” or ‘checkout list’ as it was originally termed, first published in February 1987 in the Federal Register as the “Anesthesia Apparatus Checkout Recommendations” [3]. The checklist is an important component of CRM, it is meant to provide practitioners with a standardized approach to checking equipment prior to its use in order to ensure nothing has been missed [3]. Checklists may also assist in reiterating roles and responsibilities in high acuity cases, for example during a cardiac arrest.

CRM and the Critical Care Environment

Critical Care Transport (CCT) is an essential component of the healthcare system. It provides highly trained medical teams who respond to varying type of emergencies, including the transportation of patients to specialized medical facilities, natural disaster and mass casualty incidents response as well as augmenting search and rescue teams [4]. These medical teams operating in the realm of CCT are, “by nature highly mobile and experienced in delivering care outside of the constraints of a medical facility, often with very limited resources” [4].

Due to the nature of their scope of practice and training, CCT providers have taken a leading role in the decision-making and care delivery process to patient requiring emergency medical transport [4]. CCT providers are said to, “assume an autonomous role in this environment with an expert knowledge base spanning a wide variety of specialties to deliver care for patients with time-dependent, life-threatening conditions” [4]. There is also a requirement for crewmembers to develop clinical and diagnostic reasoning abilities while managing the dynamic needs of the patient in unstructured, uncertain, and often-unforgiving environments. This unique setting is noted to become increasingly complex with the physiological effects associated with altitude-related complications, such as hypoxia, barometric pressure changes, thermal changes, dehydration, noise, vibration, gravitational forces, third spacing and fatigue. In addition to this clinical mastery, crewmembers must demonstrate effective communication skills in: patient handoff, situational awareness, as well as decision-making and crew resource management [4].

The key to better safety and fewer accidents is managing the inevitable error. Aviation and other high-reliability organizations now manage these inevitable errors by doing two things:

  1. Training teams to use specific teamwork and communication behaviours
  2. Implementing safety tools such as, procedures, protocols and checklists to name a few.
  3. These tools compliment the behaviours to detect and “trap” small errors before they become serious or fatal mistakes [5].

Gaffney, Harden and Seddon highlight an everyday occurrence of CMR in aviation with the following example: a flight crew is given a clearance by Air Traffic Control (ATC) to climb to a new altitude. The flight crew will acknowledge the new instructions from ATC and “read back” the exact altitude to which the flight has been cleared. ATC will listen for this read back and, if it not received, ATC will query the crew as to whether they heard the instructions. In the event of the flight crew reading back a different altitude than the one given, ATC can immediately intervene and correct the error. The cross-check prevents collisions between aircraft [5].

This example demonstrates both parts of the CRM safety system: precise communication between the flight crew and ATC (communication skill) and the standard operating procedure (SOP) of providing a read back (safety tool) [5].

The relevance of CRM in the healthcare setting

Crew Resource Management is noted to be consistent with the principle of “first, do no harm”. This concept is known to be the core tenet in healthcare and medicine. It is both a personal and institutional obligation [5]. Leaders in paramedicine must encourage, support and sponsor programs that make patient safety the “absolute prerequisite and cornerstone of quality care” [5], all the while organizations and their employees assure patients that they will be safe from medical errors and/or accidents [5].

Developing learning objectives for a comprehensive CRM skills training course

The use of CRM in healthcare has become far more mainstream in recent years; it has been proven to be very valuable throughout the current COVID-19 pandemic especially in the areas of airway management and Rapid Sequence Induction (RSI) and even more so when it comes to the initial approach to managing COVID positive patients.

Adapted from Gaffney, Harden and Seddon, the learning objectives that follow are provided for readers interested in developing a comprehensive CRM skills training course for their organization.

Introduction to aviation-based CRM safety programs

  • State the effect of CRM on aviation accident and incident rates
  • Understand the similarities between healthcare/medicine and aviation
  • Discuss recent results from healthcare institutions pursuing CRM patient safety programs

Alertness management and fatigue countermeasures

  • State the two causes of fatigue for healthcare providers
  • List the types of physical and mental errors produced by fatigue
  • Discuss the effect of sleep physiology on alertness
  • Discuss the effects of disrupted circadian rhythms on performance
  • List the effective countermeasures to fatigue
  • Discuss the proper nutrition to maintain alertness and prevent error

Team building

  • Describe the benefit of teamwork to healthcare teams
  • Describe the process of balancing the leader’s authority with the team’s participation
  • List six specific actions to take to create an effective team at the beginning of the case, procedure or shift
  • Assess the effectiveness of video examples of teamwork
  1. Situational awareness: Recognizing the warning sign (red flags) of impending adverse events
  2. State the history and effect of red flags training in aviation
  3. Define and recognize seven red flags unique to healthcare
  4. Identify red flags in a healthcare case study
  5. Provide the correct verbal response to the presence of a red flag

Cross-check and communication

  • State the one communication technique with a proven record of decreasing communication-based errors
  • Define the process of “cross-checking” performance
  • State the three step communication process for more effective team performance
  • Provide an effective assertive statement to change the outcome and avoid the patient safety errors in a healthcare case study

Effective team decision-making

  • State the four type of decision strategies used by teams
  • Utilize an effective team decision-making protocol and apply it to a healthcare problem
  • List four questions to ask of the team to ensure a shared mental model
  • State the most common types of decision-making error and the strategies to avoid them
  • Debriefing (performance feedback)

State

  • The most effective technique to transfer information to long-term memory
  • Three questions to ask to ensure an effective, non-threatening feedback session
  • And apply the specific question to ask to ensure better performance for next time
[5]

As it relates to critical care, the environment is challenging and very complex for both new and experienced critical care transport crewmembers. Many variables extend beyond the medical management of a patient and because clinical and flight time are irregular and unpredictable in nature it is imperative that organizations place a high-degree of importance on Crew Resource Management in an effort to ameliorate patient safety and the overall efficiency and effectiveness of the critical care team.

References

  1. Helmreich R, Merritt A, Wilhelm J. The Evolution of Crew Resource Management Training in Commercial Aviation. International Journal of Aviation Psychology. 1999;9(1):19-32.
  2. Reznek M, Smith-Coggins R, Howard S, Kiran K, Harter P, Sowb Y et al. Emergency Medicine Crisis Resource Management (EMCRM): Pilot Study of a Simulation-based Crisis Management Course for Emergency Medicine. Academy of Emergency Medicine [Internet]. 2020 [cited 9 January 2020];10(4):386-389. Available from: http://www.aemj.org
  3. University of California at San Francisco (UCSF)–Stanford University Evidence-based Practice Center. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. San Francisco: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services; 2001 p. 259.
  4. Alfes C, Steiner S, Rutherford-Hemming T. Challenges and Resources for New Critical Care Transport Crewmembers: A Descriptive Exploratory Study. Air Medical Journal. 2016;35(4):212-215.
  5. Gaffney F, Harden S, Seddon R. Crew resource management. Marblehead, MA: HCPro; 2005:5-7; 22.
Chris Farnady

Chris Farnady

Chris is a graduate of Loyalist College’s Primary Care Paramedic program (Bancroft, ON), Durham College’s (Oshawa, ON) Advance Care Paramedic and currently pursuing his Bachelor of Health Science from Thompson Rivers University. Chris began his prehospital care career in 1997 working as an EMR in Alberta’s oil and gas industry and has enjoyed the privilege of working as a Primary Care and Advanced Care Paramedic in Ontario, Northern Manitoba and Alberta. In April 2018 Chris accepted a position with Advanced Paramedic Ltd. and returned to Northern Alberta as an Advanced Care Flight Paramedic for Alberta Health Services’ transport medicine program. In his time away from work, Chris enjoys being at home with his wife and two children. Chris can be reached for comment at chris.farnady@gmail.com.

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