Crisis Resource Management, CRM, refers to the non-technical skills required for effective teamwork in a crisis situation. In addition to the nature of the task itself, numerous factors affect the successful performance of complex tasks at the level of the individual, team, and the environment.

The term CRM originated with Crew (or Cockpit) Resource Management training developed by the aviation industry in the 1970s following the realization that 70% of airline crashes were due to human error resulting from teamwork failure.

CRM training improves performance and reduces errors with evidence that this is true for aviation, military settings, and various human medical contexts (such as rapid response teams, trauma teams and Emergency Department teams). Equipping clinical team members with a suite of psychological tools to manage stress, attention, and arousal, as well as emphasizing specific team-based behaviors will improve team performance. The creation of shared, accurate but flexible mental models, as well as training and practicing methods of effective communication are key to facilitation of this improvement.

Emergency presentations often involve the sudden imposition of critically ill patients with complex needs into our clinics. Many of these patients will need urgent stabilizing and investigative procedures to be performed simultaneously, often with dire consequences if these do not happen in a timely fashion. These situations require the coordination of multiple cognitive, task-based, and systems-based resources in a dynamic context that rapidly exceeds the capacity of a single individual. Equally challenging are the communication challenges involved in controlling the interactions between individuals in a team, and the ability to perform complex tasks also depends upon the functionality of the clinical environment. Often, failure in these clinical scenarios is due to lack of shared mental models (‘the goals’), lack of clarity in roles (‘the roles’), and gaps between strategy (‘the plan’) and logistics (how the plan is executed—‘the play’).

Targeted integration of human factors theory can help manage complexity and improve performance in dynamic clinical environments. The first step, but only the first step, is awareness and adoption of some of the tools exemplified as ‘crisis resource management,’ but to create fully functioning teams, thorough debriefing and analysis of events (both successful and less successful elements) and a dynamic, nuanced approach to any challenges identified are essential.

A number of different elements are at play whenever technically or logistically complex tasks need to be performed:

Factors Affecting the Performance of Complex Tasks

Task

• Complexity: not only the complexity of the individual task and the performer, but also the setting, their trouble-shooting ability and the team members assisting and their previous interactions
• High stakes: often life-altering—relief of tension pneumothorax, drainage of pericardial effusions
• Time-critical: perfusion resuscitation in septic shock
• Incomplete information: diagnostic deficiencies, medical history, lack of imaging

Individual (HALTS hungry angry late tired stressed)

• Fatigue: shift length, appropriate breaks, and food/drink
• Sleep deprivation: overly long shifts, paperwork, colleague absence
• Emotional disturbance: personal concerns, burnout, resilience
• Ill health and physical distress: work concerns, chronic impact of the above
• Inexperience: shift management, appropriate teaching/training
• Lack of knowledge: inappropriate distribution of tasks

Team

• Role confusion: ineffective direction, lack of  task distribution
• High power distance/authority gradient: lack of approachability, lack of 360 review/debrief processes, inclusive pre-briefing and intermittent consultations, civility
• Ineffective communication techniques: closed loop, clarity, shared technical language
• Dysfunctional relationships: lack of civility and collegiality—current or historical

Environment

• Interruption
• Noise
• Handovers
• Production pressure
• Equipment failure
• Unfamiliar place and equipment

Key Principles of CRM

Many, if not all, of these factors can be mitigated by the application of the key principles of crisis resource management. 15 key principles were identified by Rall and Gaba; however, these can be reasonably (and rather more memorably) nested into 8:

• Know your environment
• Anticipate, share and review the plan
• Provide effective leadership
• Ensure role clarity and good teamwork
• Communicate effectively
• Call for help early
• Allocate attention wisely
• Distribute the workload

Know Your Environment

• Know the location and function of equipment, especially for time-critical procedures; have pre-made kits—difficult airway, pericardial drainage, thoracocentesis, etc.
• Create a logically structured, well-labelled environment; similarity of kit and layout throughout the clinic/hospital.
• Use cognitive aids, such as equipment maps, to key areas such as the ER, ICU, and surgical kit store.
• Perform regular training and create functional induction processes; ensure a degree of universality with team members—core knowledge/skills in all parts of the clinic.
• Know the role and experience of team members (to avoid role confusion); the military and emergency services use specific markings on uniforms for a reason—if unknown, ask!

Anticipate, Share and Review the Plan

• Think ahead and plan for all contingencies; pre-brief—discuss what should be coming in, what should happen, by whom, when, in what order, and what will happen after that, as well as what the micro-goals are.
• Set priorities dynamically, according to clinical need.
• Re-evaluate periodically; pause, reassess, and ask for feedback.
• Anticipate delays; consider other routes to achieve goals, set thresholds for failure alarms both time and input based.
• Use call-and-respond checklists; engaged closed loop communication.
• Share the plan with others—share the mental model; pre-brief, set goals, create roles.
• Think out loud—provide periodic briefings to verbalise priorities, goals, and clinical findings as they change; describe thoughts and observations, change plans as things change.
• Encourage team members to share relevant thoughts and plans; live, but especially as part of 10 every 10.
• Continually review the plan based on observations and response to treatment.

Provide Effective Leadership and Followership

• Employ the least confrontational approach consistent with the goal; pre-briefing and shared goals/mental model is key to this.
• Participative decision making improves team buy-in; remember that multiple leaders doesn’t work, however.
• Use a direct, authoritative approach when necessary; when time critical or life-threatening.
• Relinquish control (for temporary sub-tasks) when needed; but create timeline thresholds and ensure macro closed loop sub-task communications.
• Establish behavioural and performance expectations of team members; display exemplary collegiality and civility, correct adverse behaviours out of the crisis setting.
• Establish and maintain the team’s shared mental model of what is happening and the team’s goals; summarise progress at the top of each 10 every 10.
• Monitor and encourage group responsibility for the external and internal environments of the team to avoid being caught off guard; sharps disposal, personal clean up, personal awareness, slip hazards, PPE.
• Enable a roundtable, zero hierarchy (although this may need to be driven by the Team Leader) ‘warm’ debrief shortly after the crisis; use systems such as CPR-DO—Check Prepare Refuel Debrief Organise.

Ensure Role Clarity and Good Teamwork

• Allocate appropriate team roles.
• If team roles are changed during a task, ensure there is explicit handover (e.g., “Pablo will take over as team leader, while I help with the difficult airway”).
• Team members should show good followership principles—active, observant, critical, vocal; encourage and welcome appropriate feedback during live events, be prepared to explain and justify to remould the shared mental model; be prepared to change your plan.
• Team members, including the team leader need to be able to recognise when they are affected by stress, and develop appropriate self-care behaviours.
• All team members are equally responsible for ensuring good patient outcomes and for ensuring team member safety; be patient-centric and allo-centric.

Communicate Effectively

• Distribute needed information to team members and update the shared mental model.
• Use closed loop communication; ensure both parties actually listen.
• Be assertive and courteous, not aggressive, or submissive.
• Avoid personal attacks.
• Resolve conflict at an appropriate time.
• Maintain relationships.
• Facilitate collaborative efforts working towards a common goal.
• Double check with team members.
• Avoid unnecessary mitigating language.

Call for Help Early

• Be aware of barriers to asking for help (e.g., fear of criticism or losing face); remember the shared mental model does not include you looking omnipotent—it’s about the patient.
• Set pre-defined criteria for asking for help; task-oriented, time-oriented.
• Call for help early.
• Mobilise all available resources; know team members’ skillsets.

Allocate Attention Wisely—Avoid Fixation

• Be wary of becoming fixated on one aspect and losing situational awareness; if you are the best person for a sub-task—handover team leadership temporarily or permanently if the goals change.
• Prioritise tasks and focus on the most important task at hand; time-critical and related to the Major Body Systems.
• Delegate tasks to others (employing closed-loop goal management).
• Use all available information; using closed-loop sub-task management—Bernard goes to run the bloods, Bernard brings the results and reports them.
• Ensure life-signs monitors are observed and assessments repeated periodically; set thresholds of concern.

Distribute the Workload—Monitor and Support Team Members

• Team leader is ‘hands-off’ if possible, to maintain situational awareness and team oversight.
• Assign tasks equitably across the team, but appropriately for skillsets.
• Support team members in their tasks; don’t micro-manage.
• Reallocate roles as tasks are completed or evolve in complexity.

Managing Complexity

What about other aspects—preparatory training for individuals, both from a personal perspective and as a member of the team?

Individual team members are invariably influenced by prior experience and coping strategies, which in turn influences ‘mental posture’—the ability to remain flexible, problem-solve, and perform under acute stress, as well as influencing the team members around them. Teams are also affected by prior experience (performance of the task in question, performance of any task with the same team members) and success, mutual respect and empathy, and shared coping mechanisms. The fact that both individuals and teams are influenced by prior experience means that well-directed training can have a marked effect on improving performance and management of complex situations.