Crew Resource Management (CRM)

, Amy Gospel², Andrew Griffiths³ and Jeremy Henning⁴

(1)

Intensive Care Unit, James Cook University Hospital, Middlesbrough, UK

(2)

Tyne and Wear, UK

(3)

The York Hospital, Middlesbrough, UK

(4)

James Cook University Hospital, Middlesbrough, UK

By the end of this chapter you will be able to:

Define Crew Resource Management, Human Factors and Non-Technical Skills
Understand the importance of Crew Resource Management in the pre-hospital environment
Discuss the component factors of Crew Resource Management in pre-hospital anaesthetic practice

Pre-hospital anaesthesia (PHA) is a potentially high-risk procedure in a challenging environment. A successful outcome relies on dynamic interaction between several members of a multidisciplinary team. The skills involved can be divided into those of a technical nature, such as laryngoscopy, and those of a non-technical nature, such as teamwork and communication. These latter skills arguably play a larger part in determining the safe and successful completion of the procedure, than the individual technical skills of team-members.

Errors are an inevitable part of complex systems with human involvement, and can lead to adverse events. The ‘Swiss Cheese Model’ (Fig. 4.1) demonstrates that, occasionally, the holes in several slices of cheese can line up perfectly to allow an error to pass through without being blocked. Adverse incidents are generally the result of a sequence of coincidental circumstances, misjudgements and technical errors. These often occur on a background of latent flaws in a system, which reduce the chance for prevention.

Figure 4.1

Reason’s Swiss cheese model (Reason 2000)

The aviation industry has for many years recognised that training in non-technical skills reduces errors and improves safety. Crew (previously Cockpit) Resource Management training originated from a NASA workshop in 1979 (Cooper et al 1980), and has been embedded within the culture of the aviation industry for over three decades. In simple terms, CRM is the ability to make best use of all available personnel and resources. This requires the use of cognitive, social and personal skills that complement the technical skills required to fly. They are the ‘Non-Technical Skills’ (Box 4.1) and the ‘Human Factors’ that can result in catastrophic outcomes when they are lacking from a team.

Box 4.1: Non-Technical Skills

Situational Awareness
Teamwork
Leadership
Communication
Decision-Making
Task Management (Prioritising)

Individuals are more likely to demonstrate these qualities if they have been trained and work in an organisation that provides the culture, working environment, processes, and equipment to support good CRM.

Assurance of competency in these non-technical skills is a component of licensing and revalidation for Pilots. Many comparisons can be drawn between the highly complex system within an aeroplane cockpit, and the multiple steps and interactions required to plan, prepare and undertake medical interventions (such as PHA) in a high-pressure environment. The concepts of CRM are sometimes referred to as Team Resource Management (TRM), and this is the term used in the current PHEM curriculum. This term appears to have been originally used by the European Organisation for the Safety of Air Navigation (1996) in a document relating to enhanced teamwork for Air Traffic Management staff and is now sometimes used synonymously with CRM.

4.1 Situational Awareness

Situational awareness refers to an individual’s awareness of their immediate environment along with potential external influences, and the understanding and analysis of this to predict future events. Box 4.2 displays the three-stage model of situational awareness by Endsley (2001), along with examples of how failures in situational awareness can occur at each stage.

Box 4.2: Endsley’s Three-Stage Model of Situational Awareness

Level 1	Perception – of environmental elements (Failure to correctly perceive the situation)
Example	You attend a Road Traffic Collision (RTC) where a car has gone off the road into a hedge. There is an injured driver and injured front seat passenger. You fail to notice the large impact on the front right of the car and external ‘bulls-eye’ on the window. You therefore do not think to look for the badly injured motorcyclist 100 m further down the road in a ditch
Level 2	Comprehension – of relevant information and derivation of meaning (Failure to comprehend the situation)
Example	Attending the same RTC you note the front-right impact and presume the car may have hit either another car or perhaps the gatepost next to the hedge, before reaching its final position. You note the damaged windscreen but presume this is from the driver. You fail to think that the damage must be external as the driver was wearing a seatbelt and he has only minor facial injuries with a deflated airbag in front of him.
Level 3	Projection – of future status (Failure to project the situation into the future)
Example	Attending the same RTC you quickly assess the driver and front seat passenger. You note that the driver has minor injuries, but the passenger is shocked. You suspect he has a ruptured spleen and fractured femur, and is likely to require emergency surgery at the major trauma centre. The police officer and paramedic went to look for a possible third patient after you noted the external damage to the car, and inform you of a male motorcyclist with a head injury and reduced GCS. At this point you fail to think ahead and do not call for a second ambulance. Fifteen minutes later, after assessing and anaesthetising the motorcyclist you realise that you now have two patients requiring transfer to the major trauma centre and request assistance. Unfortunately by now the nearest ambulance is 15 miles further away attending another patient.

Lack of situational awareness may lead to poor decision-making and adverse events. A brief moment of assessment of the wider scene immediately on arrival is time well spent. Distractions must be avoided; this includes being drawn into the management of an individual patient before confirming the number of casualties and prioritising treatment. The clinician must gain ‘control’ of the scene, and an appreciation of the hazards of their working environment, as soon as possible.

Assimilating the relevant information, in a short period of time, is an essential skill of the experienced pre-hospital practitioner. In addition to the patient’s history and current condition, the mechanism of injury, available personnel and equipment, along with weather and time of day, all require consideration. Various multiagency staff (such as fire, police and ambulance crews) can be integral to the team effect, but co-ordination of effort is required. Bystanders may be helpful in remote locations, but may require management to prevent them posing further risk.

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