This document discusses crisis resource management (CRM) skills that are important for effective medical teams. It covers four key components of CRM: communication, role clarity, utilization of resources, and situational awareness. Historical evidence shows that deficiencies in these non-technical skills contribute to many medical errors. The document aims to help medical professionals understand and apply CRM principles through discussing examples from past scenarios and clinical duties.

1. Pediatrics
Crisis Resource
Management
Kevin Roy
Critical Care Medicine

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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

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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

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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)

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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

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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

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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

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Reviewing CRM Principles
•Origin of these CRM principles
•Categories and subcategories:
‐Communication
‐Role Clarity
‐Resource utilization
‐Situational Awareness
•Relationship with Latent Safety Threats

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The importance of CRM

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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

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Category 1: Communication

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Recap: Communication
• Calm and “professional” environment
• Closed loop communication
• Clear communication of critical events
• Team leader communicates plan to group
• Team members are empowered

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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?

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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

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Category 2: Role Clarity

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Recap: Role Clarity
• Team Leader Identified
• Team roles identified
• Team members focus on their roles
• Effective handoff of roles

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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

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Category 3: Utilization of Resources

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Category 3: Utilization of Resources

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Recap: Utilization of Resources
• Call for help early
• Workload distributed optimally
• Appropriate Assignments
• Appropriate equipment

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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

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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

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Category 4: Situational Awareness

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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

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Putting it all together:

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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

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Questions?