CRM: Crisis Resource Management

Evaluation of patients in general medicine and resuscitation, like stroke, for immediate treatments must be expedient, accurate, and efficient to obtain the best clinical results. The advancement of healthcare over the years has seen the development of numerous immediate response treatments, innovative imaging techniques, and the establishment of comprehensive care systems. These developments have, however, come under strain, revealing potential gaps in emergency preparedness, especially during the immediate response phase as medical professionals form impromptu teams to assess and resuscitate patients.

Critical factors in this process include patient characteristics, healthcare resources, team dynamics, and healthcare providers' well-being. These aspects encompass the entire survival chain, from immediate assessment to admission and discharge.

While technical skill proficiency is essential to successfully carry out immediate medical responses, numerous non-technical skills also play a key role. CRM provides a framework for these skills, which includes situational awareness, triage and prioritization, cognitive load reduction, role clarity, communication, and debriefing. Originally termed as "crew resource management" in the aviation industry, where human errors can lead to disastrous consequences, CRM is increasingly acknowledged within medicine and has already become deeply ingrained in specialties such as emergency medicine, critical care, and anesthesia. These specialties share a common thread with immediate response medical care, all centred around the resuscitation process.

On the general medicine ward, similar to the stroke unit, is where most of the acute care takes place. CRM techniques can be applied in the unit to ensure that patients receive timely and appropriate care, and that the patient's condition is monitored closely. This can include things like clear communication among the stroke team, the use of checklists and protocols, and the implementation of stroke alert protocols.

Simulation is a powerful tool that can be used in conjunction with CRM to improve the care of patients with acute stroke and the same for medical patients. Simulation allows healthcare teams to practice and refine their skills in a controlled environment, and can be used to replicate real-world clinical scenarios. When coupled with CRM techniques, simulation can enhance teamwork and collaboration, as well as improve the identification and management of high-risk situations and critical events in the care of patients with acute stroke or general medicine issues.

In conclusion, CRM is a framework that can be applied in various areas of acute medicine, such as the emergency department, medical imaging, angiography suite, and the stroke unit, to improve the care of patients and the proficiency of providers.

CRM techniques, such as effective communication, situation awareness, and decision making, can be used to ensure that patients receive timely and appropriate care, and that the patient's condition is monitored closely. When coupled with simulation, CRM can enhance teamwork and collaboration, and improve the identification and management of high-risk situations.

See below for a video debrief about CRM and its use in Code Blue resuscitation.

We start off with a quick re-cap of the use of Crisis Resource Management framework in code resuscitation as some take-away messages from a simulation event.

Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness

Cliff Reid, Peter Brindley, Chris Hicks, Simon Carley, Clare Richmond, Michael Lauria, and Scott Weingart
"The primary survey assessment is a cornerstone of resuscitation processes. The name itself implies that it is the first step in resuscitation. In this article, we argue that in an organized resuscitation the primary survey must be preceded by a series of steps to optimize safety and performance and set the stage for the execution of expert team behavior. Even in the most time critical situations, an effective team will optimize the environment, perform self-assessments of personal readiness and participate in a preemptive team brief. We call these processes the ‘zero point survey’ as it precedes the primary survey. This paper explains the rationale for the zero point survey and describes a structured approach designed to be suitable for all resuscitation situations." - paper abstract,  see original paper
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Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care

Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart, and Houman Khosravani (corresponding author)
"Background and purpose: Management of stroke patients in the acute setting is a high-stakes task with several challenges including the need for rapid assessment and treatment, maintenance of high-performing team dynamics, management of cognitive load affecting providers, and factors impacting team communication. Crisis resource management (CRM) provides a framework to tackle these challenges and is well established in other resuscitative disciplines. The current Coronavirus Disease 2019 (COVID-19) pandemic has exposed a potential quality gap in emergency preparedness and the ability to adapt to emergency scenarios in real time.
Methods: Available resources in the literature in other disciplines and expert consensus were used to identify key elements of CRM as they apply to acute stroke management.
Results: We outline essential ingredients of CRM as a means to mitigate nontechnical challenges providers face during acute stroke care. These strategies include situational awareness, triage and prioritization, mitigation of cognitive load, team member role clarity, communication, and debriefing. Incorporation of CRM along with simulation is an established tool in other resuscitative disciplines and can be incorporated into acute stroke care.
Conclusions: As stroke care processes evolve during these trying times, the importance of consistent, safe, and efficacious care facilitated by CRM principles offers a unique avenue to alleviate human factors and support high-performing teams."  - paper abstract,  see original paper
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Here are several videos (made when at Western University, ICU Bootcamp) to help resident MDs with some introductory concepts around airway management, vascular access (by Dr. Robert Arntfield, WesternSono.ca), ICU sedation (also by Dr. Robert Arntfield), and sepsis/septic shock. Hope you find these useful; there are many other online resources that are great including podcasts, and vidoes, checkout emcrit.org (my collaborator, Dr. Scott Weingart), specifically the emcrit archives.