Healthcare is a high-stakes industry that is prone to crises. This is very much true for emergency medicine and anesthesiology. Healthcare providers must treat critically sick patients, while not being always 100% sure about the final diagnosis. Treatments are often begun in environments with limited resources under circumstances that are disturbing and disrupting (multiple sick patients at the same time, loud environment)
Even though acute care medicine in Europe belongs to the best worldwide, patient harm commonly occurs. Still, 70% of mistakes in acute care medicine are originating out of the “human factors” complex. Still, training on human factors and coping strategies seems to be rare for healthcare providers. [Rall M, Gaba DM (2009) Human performance and patient safety. In: Miller RD (Hrsg.) Miller’s Anesthesia. Elsevier Churchhill Livingstone, Philadelphia, S 93–150].
For many years it is well known what challenges complex organizations (including healthcare) are dealing with. Different industries have been successfully working on these challenges for quite a while. In different high-risk-organizations they installed programs to deal with human factors and their trainings became mandatory, successful, and well-liked.
In healthcare it seems that a broad implementation of such training programs is lacking for decades. For many teams in (pre-)hospital emergency care it is quite common to experience certain (rare) acute diseases for the first time when being without supervision of a more senior specialist, f.e. when being an emergency physician on the ambulance or helicopter. Not surprisingly mistakes are happening, patients and healthcare professionals suffer afterwards [Gries A, et al. Realistic assessment of the physician-staffed emergency services in Germany. Anaesthesist 2006; 55: 1080–1086]
Not surprisingly, human factors are hard predictors for patient outcomes and errors in this area are tragic because they are usually not very hard to avoid. [Rall M, und Team TüPASS. Lernen aus kritischen Ereignissen auf der Intensivstation. Intensivmedizin up2date 2010: 6: 85–104]. As a result, more and more medical specialties start to address these issues systematically by implementing curricula, where also human factors are addressed.
Though, knowledge and training in this area should be mandatory for all healthcare providers like in other industries – neither an option nor should they be a loose recommendation.
One widely used tool, not just in healthcare, is CRM (Crisis Resource Management). It originates out of aviation where it was originally called Cockpit or Crew Resource Management. In the 1970s, the National Transportation Safety Board found that human error contributed to over 70% of aviation accidents [Helmreich RL. Does CRM training work? Air Line Pilot. 1991 May;60(5):17-20].
Crisis Resource Management in general refers to the non-technical skills required for effective teamwork in a crisis situation, and it is shown in many branches that CRM training improves performance and reduces errors.
Also in healthcare, in mid 80s, David Gaba and his team found that, like in aviation some years before, traditional training in anesthesiology focused on the technical aspects of patient management and less or not at all on the non-technical aspects [Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth. 2010 Jul;105(1):3-6.]
As a result, Anesthesia Crisis Resource Management (ACRM) was developed based on the ideas and learnings from aviation CRM. A simulation-based course that focused on crucial teamwork skills such as dynamic decision-making, interpersonal communication, and team leadership was started.
It included techniques and processes that made sure that influences on “human errors” were detected and showed ways how to deal with them and avoid harm to patients.
Rall and Gaba (2005) have identified the following 15 key (CRM) principles:
- Know the environment
- Anticipate and plan
- Call for help early
- Exercise leadership and followership
- Distribute the workload
- Mobilize all available resources
- Communicate effectively
- Use all available information
- Prevent and manage fixation errors
- Cross (double) check
- Use cognitive aids
- Re-evaluate repeatedly
- Use good teamwork
- Allocate attention wisely
- Set priorities dynamically
Literature showing effectivity of such CRM Trainings is meanwhile extensively available.
Not surprisingly, a once in a lifetime training is not enough “to get rid of human factors”. CRM Training requires a certain intensity and regularity since it’s about training our behavior and not just a “simple skill”.
CRM Trainings combined with medical simulation ideally take a day (at least in the beginning), participants should train in small group sizes with a high ratio of trainers/students. Ideally these trainings are repeated every year, in the ERC guidelines the recommendation is even shorter.
Written by Lukas Drabauer from Alpha Medical Concepts (AMC)
