Healthcare is a high-stakes industry that is prone to crises; this is especially true for acute care specialties such as anesthesiology and emergency medicine, in which healthcare practitioners must treat critically ill patients while facing diagnostic ambiguity, resource limitations, and numerous disruptions in chaotic work environments. To deliver safe and effective patient care, medical professionals must execute highly coordinated team-based strategies. Crisis resource management (CRM) refers to a set of principles dealing with cognitive and interpersonal behaviors that contribute to optimal team performance.
Crisis resource management has its origins in the aviation industry. In the 1970s, the National Transportation Safety Board found that human error contributed to over 70% of aviation accidents. More in-depth investigations revealed that the majority of errors were related to teamwork failures rather than deficiencies in knowledge or technical skills. This critical recognition led to the development of simulation-based “crew resource management” training programs that focused on core teamwork behaviors such as leadership, communication, situational awareness, and resource utilization. Crew resource management training has been a global standard in aviation since the 1990s and is now a mandatory component of aircrew training.
In healthcare, anesthesiology was the first specialty to incorporate CRM principles into the training of its clinicians. In the late 1980s, David Gaba and his colleagues recognized that, like aviation, traditional training in anesthesiology focused on the technical aspects of patient management and not on the behavioral aspects of team performance. To address this, they developed and implemented Anesthesia Crisis Resource Management (ACRM), a simulation-based course that focused on crucial teamwork skills such as dynamic decision-making, interpersonal communication, and team leadership. ACRM has been well-received and widely adopted by anesthesiologists around the world.
Following their success in aviation and anesthesiology, simulation-based CRM training programs were soon developed in other high-risk, high-acuity medical specialties, including emergency medicine, critical care, and neonatology. Today, CRM courses can be found in almost every medical specialty as well as in other healthcare professions, including nursing, pharmacy, and emergency medical services.
Adverse events in healthcare are generally the result of complex combinations of human factors and systems failures. The primary purpose of CRM training is to provide a team-based approach to averting and mitigating medical crises. The key principles taught in CRM are designed to facilitate earlier detection of potential adverse outcomes and empower healthcare practitioners to intervene more effectively. While each crisis management course utilizes a slightly different set of principles, CRM can be summarized through the following eight teamwork behaviors: leadership, communication, anticipation and planning, resource utilization, workload distribution, situational awareness, triage and prioritization, and management of disruptions.
Effective teams require effective leadership. Team leaders are responsible for assigning specific roles to other team members and monitoring their actions. Leaders should maintain a global view during a crisis and avoid fixating on isolated details. They should continually synthesize key information and be adaptive to dynamic situations. Leaders should not only be open to feedback but should actively engage team members in decision making to create a collaborative environment. Finally, leaders should balance confidence and humility so that they can make calm and timely decisions while also recognizing their limitations. It is important to note that an effective leader requires an effective team. Team members should have a shared understanding of the team’s goals, recognize their individual roles within the team, be ready to support each other, and feel empowered to speak up to request assistance or share information.
Failures in communication are the leading cause of medical errors. Thus, effective communication is critical to the success of any team. Communication should be complete, clear, brief, and timely. Teams should routinely employ closed-loop communication to ensure that messages are properly received. Team members should aim to be assertive yet respectful when communicating. Finally, the team leader should promote bidirectional communication to facilitate knowledge-sharing and inquiry.
Anticipation and planning
In healthcare, sudden unexpected events can have serious negative consequences for patients and their medical teams. By thinking ahead and anticipating what might happen, teams can plan for changes to the patient or environment. Planning can take place long before an emergency (e.g., developing and practicing a hospital-wide disaster plan), immediately before a high-risk situation (e.g., conducting a pre-brief to prepare for the arrival of a critically ill patient), or during a crisis (e.g., providing an interim summary during a complex patient resuscitation). By anticipating and planning, teams can develop a shared mental model, prioritize tasks, promote workplace safety, decrease stress and anxiety, and optimize patient care.
Resources for the effective management of a medical crisis include personnel, equipment, and cognitive aids. The accessibility and utility of these resources may vary depending on the clinical setting, time of day, and clinician expertise. Additionally, resources that would typically be apparent during routine patient care might easily be overlooked during stressful crises. Thus, teams should continually survey their environment to identify all available resources. When to mobilize each resource will depend on the specific needs of the team and the complexity of the medical crisis. In general, teams should call for help early and activate additional resources with enough lead time to have an impact on patient outcomes.
During medical crises, teams must perform a multitude of tasks almost simultaneously. Individual team members can quickly become overwhelmed if asked to perform too many tasks at once or tasks beyond their skill set. Balancing the workload is important for establishing role clarity, maximizing efficiency, and ensuring the safety of patients and staff. If possible, teams should distribute roles and tasks before the start of a high-risk situation. However, pre-planning may not be sufficient as new tasks and challenges may unexpectedly arise during a crisis. The team leader is responsible for assigning tasks to appropriate personnel and continually monitoring their actions to determine whether the workload needs redistributing.
Situational awareness refers to an individual’s ability to perceive relevant data from their surroundings, process the information and determine its impact on current goals, and utilize this understanding to predict future events. During a medical crisis, having situational awareness allows teams to identify and respond to changes in patient status rapidly. Team members should continually reassess the patient and clinical environment and remain sensitive to subtle cues. They should periodically check in with each other to ensure that decisions are being made using the most accurate and updated information. This cross-check establishes a shared mental model that enables teams to become proactive, rather than reactive, during a crisis.
Triage and prioritization
Medical crises often demonstrate a mismatch between the number of tasks that require completion and the resources available to address those tasks. Teams should rapidly determine the criticality of each task and prioritize those that are more important for optimizing patient outcomes. Pre-planning is essential to ensure that team members have a unified approach to triaging new tasks and challenges. The team leader is responsible for reevaluating the situation and reprioritizing tasks as the patient’s condition changes, and additional information becomes available. In certain high-acuity specialties such as emergency medicine and trauma surgery, healthcare teams must manage multiple patients simultaneously. In these settings, it is even more important to perform effective triage and prioritization to avoid adverse events. For mass casualty incidents, teams should use established triage protocols to coordinate patient care efficiently.
Management of disruptions
Healthcare teams often work in dynamic environments where they encounter frequent disruptions. Some interruptions (e.g., an overhead announcement stating that there is a fire in the vicinity) require immediate attention and resources. In contrast, others serve as distractions that can negatively impact a team’s performance. Teams should quickly and accurately assess the urgency of each disruption to determine if attention to the disruption can be delayed. If an immediate intervention is necessary, the team leader should decide what resources are to be delegated to this task. In the case of distractions originating from individuals, teams should aim to avert the distraction and avoid escalation. These individuals should receive reassurance that their needs and concerns will be addressed promptly once the medical crisis has been stabilized.
Simulation-based training offers a unique opportunity for healthcare teams to practice and assess CRM behaviors while managing realistic clinical scenarios in a controlled setting without posing a threat to the safety of real patients. CRM curricula should be individualized to meet the needs of specific learner populations and practice environments. Scenarios should be designed to provide participants with opportunities to practice and demonstrate specific crisis management skills deliberately. Finally, instructors should facilitate a focused debriefing after each simulation experience to give the teams immediate feedback on their performance.
When planning a CRM curriculum, it is essential to note that one size does not fit all. Each training program may have different goals for and constraints on implementing a CRM course for its learners. Thus, it is essential first to perform a needs assessment to identify the most critical teamwork competencies for a particular learner group and clinical environment. This can be accomplished by reviewing and characterizing the factors contributing to prior real-life crisis events that resulted in suboptimal patient outcomes. Additionally, each healthcare team is uniquely comprised of individuals with various backgrounds and capabilities. As much as possible, the composition of the learner population of a CRM course should reflect the makeup of the real-life medical team. A multi-disciplinary, multi-professional approach to teamwork training provides learners with the richest and most realistic simulation experience possible.
After identifying learner needs, instructors should develop a simulation-based curriculum that systematically addresses each of the targeted CRM principles. It may be tempting to create scenarios that incorporate many or all CRM competencies at once, especially if simulation time and resources are limited. However, teamwork training is such a dynamic process that the curriculum will likely have a more significant impact if specific scenarios are dedicated to addressing a defined subset of CRM concepts. Because the scope of any one simulation scenario will be limited, instructors should develop an array of situations to train the entire set of targeted CRM behaviors. Additionally, since effective crisis management requires the successful integration of a sophisticated collection of cognitive and interpersonal skills, teamwork training cannot be accomplished in a single simulation session. Mastery of CRM concepts requires that educators and learners engage in a continuous cycle of practice, feedback, and refinement.
The next step is to define specific and measurable learning objectives for each of the targeted CRM principles. Learning objectives serve as the foundation for curriculum development and must be specific enough to guide the construction of individual simulation scenarios. Learning objectives also provide a framework for debriefing and should be measurable to allow faculty to assess learners accurately. Measurability also enables course developers to determine the effectiveness of their curriculum.
When crafting a CRM simulation scenario, it is crucial to select an appropriate clinical context for learners to engage in teamwork training. Ideally, medical management should be challenging but not mysterious, so that participants can focus on how they can improve their CRM skills instead of debating the medical details of the case. Next, trigger events should be embedded throughout the scenario to provide learners with structured opportunities to display specific CRM behaviors. These trigger events are predetermined prompts within the scenario that are designed to elicit a set of expected critical actions. Critical measures should be objective, measurable, and linked to the predefined learning objectives of the scenario. The ability or failure to perform the expected critical actions indicates whether learners possess the targeted crisis management skills.
Structured debriefing is a critical component of simulation-based CRM training. While much learning occurs during a simulation, post-scenario debriefing allows participants to review their performance and synthesize key teamwork concepts. Debriefing should occur immediately after each simulation experience and should focus on the processes involved in optimizing specific crisis management skills instead of the medical outcomes of team efforts. The role of the debriefer is to facilitate and direct the flow of the discussion. Whenever possible, the debriefer should connect discussion points back to discrete CRM principles and learning objectives. If available, video playback may be used to highlight specific team behaviors and trigger discussion on strategies for improvement.
Several behavioral rating scales have been developed to assess healthcare teams on various CRM competencies. Some of the most well-known rating systems include the Anesthetists’ Non-Technical Skills System, the Observational Teamwork Assessment of Surgery, the Communication and Teamwork Skills Assessment, the Mayo High-Performance Teamwork Scale, and the Ottawa Crisis Resource Management Global Rating Scale. These evaluation tools serve to quantify team performance of crisis management skills and can be used to facilitate debriefing sessions or measure the effectiveness of a CRM training program.
Today, it is widely recognized that simulation-based CRM training is an essential component of healthcare education. There is abundant evidence from almost every high-acuity medical specialty and healthcare profession supporting the effectiveness of simulation-based CRM training programs in promoting the acquisition of crisis management skills. However, at present, there is less available data demonstrating its downstream impact on patient care. Potential explanations include the absence of a universal definition for CRM, the lack of clarity as to what constitutes CRM training, and the dearth of measurement tools to quantify its effects on patient safety. Interestingly, even in the aviation industry, where teamwork training is more established than in healthcare, there is little high-quality evidence that these educational interventions save lives or aircraft. Thus, while further research on patient-level outcomes is needed, healthcare teams must continue to utilize simulation-based CRM training to practice and assess teamwork behaviors.
To deliver safe and effective patient care in dynamic work environments, healthcare practitioners must employ highly organized, team-based strategies. Crisis resource management consists of a set of teamwork principles that can be utilized to avert and mitigate medical crises. CRM can be summarized through the following eight teamwork behaviors: leadership, communication, anticipation and planning, resource utilization, workload distribution, situational awareness, triage and prioritization, and management of disruptions. It is clear that simulation-based CRM training improves the cognitive and interpersonal behaviors of medical professionals in simulated settings. There is also a growing body of evidence demonstrating the effectiveness of CRM training programs in enhancing team performance and reducing adverse patient outcomes in the real-life clinical workplace. As such, simulation-based CRM training is an essential component of educational initiatives aimed at improving healthcare delivery and patient safety.
|||Cheng A,Donoghue A,Gilfoyle E,Eppich W, Simulation-based crisis resource management training for pediatric critical care medicine: a review for instructors. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2012 Mar; [PubMed PMID: 21499181]|
|||Howard SK,Gaba DM,Fish KJ,Yang G,Sarnquist FH, Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviation, space, and environmental medicine. 1992 Sep; [PubMed PMID: 1524531]|
|||Helmreich RL, Does CRM training work? Air line pilot. 1991 May; [PubMed PMID: 11538205]|
|||Helmreich RL,Merritt AC,Wilhelm JA, The evolution of Crew Resource Management training in commercial aviation. The International journal of aviation psychology. 1999; [PubMed PMID: 11541445]|
|||Gaba DM, Crisis resource management and teamwork training in anaesthesia. British journal of anaesthesia. 2010 Jul; [PubMed PMID: 20551023]|
|||Holzman RS,Cooper JB,Gaba DM,Philip JH,Small SD,Feinstein D, Anesthesia crisis resource management: real-life simulation training in operating room crises. Journal of clinical anesthesia. 1995 Dec; [PubMed PMID: 8747567]|
|||Reznek M,Smith-Coggins R,Howard S,Kiran K,Harter P,Sowb Y,Gaba D,Krummel T, Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2003 Apr; [PubMed PMID: 12670855]|
|||Hicks CM,Bandiera GW,Denny CJ, Building a simulation-based crisis resource management course for emergency medicine, phase 1: Results from an interdisciplinary needs assessment survey. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2008 Nov; [PubMed PMID: 18638031]|
|||Lighthall GK,Barr J,Howard SK,Gellar E,Sowb Y,Bertacini E,Gaba D, Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents. Critical care medicine. 2003 Oct; [PubMed PMID: 14530748]|
|||Halamek LP,Kaegi DM,Gaba DM,Sowb YA,Smith BC,Smith BE,Howard SK, Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics. 2000 Oct; [PubMed PMID: 11015540]|
|||Moorthy K,Munz Y,Forrest D,Pandey V,Undre S,Vincent C,Darzi A, Surgical crisis management skills training and assessment: a simulation[corrected]-based approach to enhancing operating room performance. Annals of surgery. 2006 Jul; [PubMed PMID: 16794399]|
|||Heaton SR,Little Z,Akhtar K,Ramachandran M,Lee J, Using simulation to train orthopaedic trainees in non-technical skills: A pilot study. World journal of orthopedics. 2016 Aug 18; [PubMed PMID: 27622147]|
|||Ounounou E,Aydin A,Brunckhorst O,Khan MS,Dasgupta P,Ahmed K, Nontechnical Skills in Surgery: A Systematic Review of Current Training Modalities. Journal of surgical education. 2019 Jan - Feb; [PubMed PMID: 30122636]|
|||Coppens I,Verhaeghe S,Van Hecke A,Beeckman D, The effectiveness of crisis resource management and team debriefing in resuscitation education of nursing students: A randomised controlled trial. Journal of clinical nursing. 2018 Jan; [PubMed PMID: 28401617]|
|||Tremblay ML, Simulation-based Crisis Resource Management in Pharmacy Education. American journal of pharmaceutical education. 2018 Aug; [PubMed PMID: 30181673]|
|||Miller GT,Gordon DL,Issenberg SB,LaCombe DM,Brotons AA, Teamwork. University of Miami uses competition to sharpen EMS team performance. JEMS : a journal of emergency medical services. 2001 Dec; [PubMed PMID: 11771373]|
|||Reason J, Beyond the organisational accident: the need for [PubMed PMID: 15576688]|
|||Eppich WJ,Brannen M,Hunt EA, Team training: implications for emergency and critical care pediatrics. Current opinion in pediatrics. 2008 Jun; [PubMed PMID: 18475092]|
|||Carne B,Kennedy M,Gray T, Review article: Crisis resource management in emergency medicine. Emergency medicine Australasia : EMA. 2012 Feb; [PubMed PMID: 22313554]|
|||Reid J,Stone K,Brown J,Caglar D,Kobayashi A,Lewis-Newby M,Partridge R,Seidel K,Quan L, The Simulation Team Assessment Tool (STAT): development, reliability and validation. Resuscitation. 2012 Jul; [PubMed PMID: 22198422]|
|||Rosenman ED,Fernandez R,Wong AH,Cassara M,Cooper DD,Kou M,Laack TA,Motola I,Parsons JR,Levine BR,Grand JA, Changing Systems Through Effective Teams: A Role for Simulation. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2018 Feb; [PubMed PMID: 28727258]|
|||Clancy CM,Tornberg DN, TeamSTEPPS: assuring optimal teamwork in clinical settings. American journal of medical quality : the official journal of the American College of Medical Quality. 2007 May-Jun; [PubMed PMID: 17485563]|
|||Gardner AK,DeMoya MA,Tinkoff GH,Brown KM,Garcia GD,Miller GT,Zaidel BW,Korndorffer JR Jr,Scott DJ,Sachdeva AK, Using simulation for disaster preparedness. Surgery. 2016 Sep; [PubMed PMID: 27206335]|
|||Evain JN,Perrot A,Vincent A,Cejka JC,Bauer C,Duclos A,Rimmelé T,Lehot JJ,Lilot M, Team planning discussion and clinical performance: a prospective, randomised, controlled simulation trial. Anaesthesia. 2019 Apr; [PubMed PMID: 30768684]|
|||Goldhaber-Fiebert SN,Lei V,Nandagopal K,Bereknyei S, Emergency manual implementation: can brief simulation-based or staff trainings increase familiarity and planned clinical use? Joint Commission journal on quality and patient safety. 2015 May; [PubMed PMID: 25977248]|
|||Schulz CM,Endsley MR,Kochs EF,Gelb AW,Wagner KJ, Situation awareness in anesthesia: concept and research. Anesthesiology. 2013 Mar; [PubMed PMID: 23291626]|
|||Lerner EB,Schwartz RB,Coule PL,Weinstein ES,Cone DC,Hunt RC,Sasser SM,Liu JM,Nudell NG,Wedmore IS,Hammond J,Bulger EM,Salomone JP,Sanddal TL,Markenson D,O'Connor RE, Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster medicine and public health preparedness. 2008 Sep; [PubMed PMID: 18769263]|
|||Ziv A,Wolpe PR,Small SD,Glick S, Simulation-based medical education: an ethical imperative. Academic medicine : journal of the Association of American Medical Colleges. 2003 Aug; [PubMed PMID: 12915366]|
|||Petrosoniak A,Hicks CM, Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Current opinion in anaesthesiology. 2013 Dec; [PubMed PMID: 24113265]|
|||Buljac-Samardzic M,Dekker-van Doorn CM,van Wijngaarden JD,van Wijk KP, Interventions to improve team effectiveness: a systematic review. Health policy (Amsterdam, Netherlands). 2010 Mar; [PubMed PMID: 19857910]|
|||Rosen MA,Salas E,Wu TS,Silvestri S,Lazzara EH,Lyons R,Weaver SJ,King HB, Promoting teamwork: an event-based approach to simulation-based teamwork training for emergency medicine residents. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2008 Nov; [PubMed PMID: 18638035]|
|||Fanning RM,Gaba DM, The role of debriefing in simulation-based learning. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2007 Summer; [PubMed PMID: 19088616]|
|||Rudolph JW,Simon R,Raemer DB,Eppich WJ, Debriefing as formative assessment: closing performance gaps in medical education. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2008 Nov; [PubMed PMID: 18945231]|
|||Fletcher G,Flin R,McGeorge P,Glavin R,Maran N,Patey R, Anaesthetists' Non-Technical Skills (ANTS): evaluation of a behavioural marker system. British journal of anaesthesia. 2003 May; [PubMed PMID: 12697584]|
|||Healey AN,Undre S,Vincent CA, Developing observational measures of performance in surgical teams. Quality [PubMed PMID: 15465953]|
|||Frankel A,Gardner R,Maynard L,Kelly A, Using the Communication and Teamwork Skills (CATS) Assessment to measure health care team performance. Joint Commission journal on quality and patient safety. 2007 Sep; [PubMed PMID: 17915529]|
|||Malec JF,Torsher LC,Dunn WF,Wiegmann DA,Arnold JJ,Brown DA,Phatak V, The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2007 Spring; [PubMed PMID: 19088602]|
|||Kim J,Neilipovitz D,Cardinal P,Chiu M,Clinch J, A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study. Critical care medicine. 2006 Aug; [PubMed PMID: 16775567]|
|||Fung L,Boet S,Bould MD,Qosa H,Perrier L,Tricco A,Tavares W,Reeves S, Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. Journal of interprofessional care. 2015; [PubMed PMID: 25973615]|
|||Meneer J, Why crisis resource management and evidence-based medicine make uncomfortable bedfellows. Emergency medicine Australasia : EMA. 2012 Oct; [PubMed PMID: 23039303]|