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2013 Pediatric Fellows Boot Camp_CRM

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  • 1. Pediatrics Crisis Resource Management Kevin Roy Critical Care Medicine
  • 2. Page 1 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics What is CRM • Encompasses skills crucial to functional teams • Non-Technical Behavioral skills ‐ Team Roles/Leadership ‐ Communication ‐ Resource Utilization ‐ Situational Awareness/Mental Modeling • Historical Significance • Practical Applications of CRM principles ‐ Scenarios ‐ Clinical Duties
  • 3. Page 2 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Before we Start: • Introductions • Goals For Discussion 1. Review Importance OF CRM Skills 2. Understand Components of CRM 3. Discuss how Each Component is Applicable to Scenarios/Experiences 4. Discuss how CRM Skills are Applicable to Work Environment 5. Safe Environment to Learn from the Group’s Pooled Experiences
  • 4. Page 3 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Historical Importance of CRM •67% of Aviation crashes were from communication, leadership and other team training deficiencies •70% of mistakes in medicine due to human error •Communication is deficient in 70% of perinatal sentinel events (Joint Commission) •Mock code training improved survival after cardiac arrest from 33% to 50% (Andreatta P et al, 2011 Pediatr Crit Care Med) •Hasbro Children's hospital showed decreased medical error rates with simulation-based team training from 30.9% to 4.4% (CHCA, 2008)
  • 5. Page 4 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics CRM throughout TCH •TCH Sentinel Events: Nearly all had a recognizable deficiency in CRM Skills ‐63% Lack of Information Sharing ‐45% Lack of Clear Hierarchy ‐45% Poor Teamwork Coordination ‐34% Poor Communication Style ‐21% Lack of Clarity Team Roles ‐Only 13% Fatigue, 16% Thought Process •Relationship with Latent Safety Threats
  • 6. Page 5 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics CRM at TCH: PICU Code Debriefings •Only 2 events(6%) were perceived as error-free • Systems issues were identified by at least 1 team member in 60% of events •BLS/PALS deficiencies in 60% of events •CRM deficiencies in 83% of events
  • 7. Page 6 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics CRM Deficiencies in PICU Codes •Communication Deficiencies 45 % •Closed Loop Communication •Team Roles Deficiencies 54% ‐ 46% Lack of clarity about team leadership •Situational Awareness 32% ‐ Available information not utilized and Planning for Crisis •Utilization of Resources 18% ‐ Appropriate Help not called early
  • 8. Page 7 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Reviewing CRM Principles •Origin of these CRM principles •Categories and subcategories: ‐Communication ‐Role Clarity ‐Resource utilization ‐Situational Awareness •Relationship with Latent Safety Threats
  • 9. Page 8 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics The importance of CRM
  • 10. Page 9 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Communication •… Some people are just good at it •… You know it when you see it •Communication is made up of Specific Crucial Components ‐ Closed Loop Communication ‐ Specific to person, place, and thing ‐ Assertive (but Calm) • “Non threatening way of garnering attention” • Avoid Unnecessary Vagueness ‐ Standardized Critical Language • “Code, Pulseless, CPR, Pulmonary HTN Crisis” • SBAR, TEAM STEPS, CUS (Concerned, Unsafe, Scared) •Examples
  • 11. Page 10 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Category 1: Communication
  • 12. Page 11 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics
  • 13. Page 12 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Recap: Communication • Calm and “professional” environment • Closed loop communication • Clear communication of critical events • Team leader communicates plan to group • Team members are empowered
  • 14. Page 13 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Team Roles •Depend on the Situation •Code/Potential Code: ‐ Team Leader ‐ Airway ‐ Cardiovascular ‐ Bed Side RN ‐ Code Cart ‐ Other: Runner, Crowd Control/Parental Support, Documenter •One Role : One Person ‐ Trust Other Roles ‐ Team Leader’s Responsibility to assign? ‐ Switching possible If needed or new personnel arrive •Other Situations or Examples?
  • 15. Page 14 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Leadership •Leadership: Definition? •Command the team ‐Identify Early ‐Final Decision Maker (not omniscient decision maker) ‐Maintain Calmness ‐Stand Back ‐Key component to other CRM skills •Lessoning the impact of hierarchy ‐“Leader” doesn’t necessitate “Followers” ‐Allowing good ideas ‐Bringing out good ideas
  • 16. Page 15 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Category 2: Role Clarity
  • 17. Page 16 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Recap: Role Clarity • Team Leader Identified • Team roles identified • Team members focus on their roles • Effective handoff of roles
  • 18. Page 17 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Utilization of Resources •Right People, Right Equipment, at the Right Time •Maximizing potential of those resources ‐Right role for each person ‐Using Equipment correctly •Getting the resources you will need 5 minutes from now •Examples
  • 19. Page 18 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Category 3: Utilization of Resources
  • 20. Page 19 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Category 3: Utilization of Resources
  • 21. Page 20 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Recap: Utilization of Resources • Call for help early • Workload distributed optimally • Appropriate Assignments • Appropriate equipment
  • 22. Page 21 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Situation Awareness •Decisions are based on percieved situation •Rapid assessment ‐Allows appropriate management decisions •Continual Assessment: Environment, Patient, and Team ‐Knowledge of patients past, present, future ‐Allows paradigm shift when on “wrong path” •Goal: One Big Picture from many small pieces •Examples of Situation Awareness ‐Benefited from recognition or challenging recognition
  • 23. Page 22 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Mental Modeling as a tool •Stating what is known …. Stating what is not known • … What are we missing • … This is what we are going to do next ‐May Include Contingencies •Encompasses other CRM skills ‐Communication: assertive but not authoritarian ‐Team Roles/Leadership:Affect on leader/group emotion ‐Situational Awareness: refines situational awareness/shared cognition ‐ Resource Utilization: allows others to predict what is needed •Examples
  • 24. Page 23 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Category 4: Situational Awareness
  • 25. Page 24 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Recap: Situational Awareness • Utilize all available information • Anticipate and plan for crises • Use mental modeling to create common understanding • Adjust situational awareness when faced with new information
  • 26. Page 25 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Putting it all together:
  • 27. Page 26 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Overall Impression: 1) How is this applicable to you 2) Is it realistic, is it possible 3) What are the challenges/roadblocks 4) What is next this week and beyond
  • 28. Page 27 xxx00.#####.ppt 7/3/2013 1:16:46 PM Pediatrics Questions?