Sunday, November 25, 2012

Joris explains CRM in the PICU @UMCN

I recently cited an excellent article about the use of Crew Resource Management (CRM) in intensive care units.  Now I have had a chance to visit a place where they are trying it out.  Joris Lemson, MD PH.D., is medical director of the pediatric intensive care unit at Radboud University Nijmegen Medical Centre in the Netherlands. Joris and his colleagues (strongly supported by Professor Johannes G. van der Hoeven) have been testing out CRM principles in their unit for over a year.

You might recall from the article that there are several aspects of this approach.  When people are trained in CRM, the key subjects in the syllabus are: Situational awareness and recognition of adverse situations; Human errors and non-punitive response; Communication and crosscheck techniques; Giving and receiving performance feedback; Management of stress, workload and fatigue; Creating and maintaining team structure and climate; Leadership; and Risk management and decision-making.

The crews in airplane cockpits often have a written set of protocols on hand as they carry out the aspects of CRM.  Indeed, there and in places like Navy submarines, it would be unthinkable to carry out certain procedures without the written checklist on hand.  The PICU folks decided that a similar approach might have value as an awareness and decision-making guide, and so they produced this laminated card to be an aide-mémoire.  In one sense, this is standard checklist items for intubating a patient--items related to equipment, the patient's position, the staff, and the procedure itself (including a pre-procedure briefing.)  On the other side, there is an elaboration of the briefing procedure, a description of the post-procedure debriefing, and a list of required supplies.

But, as Captain Sullenberger has said: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it."

I think many ICU doctors and nurses reading this would find most of the items in the Radboud procedure to be routine.  I think, though, that most would have to admit that their process is not as standardized as that found in this PICU.  I bet, too, that most of them would not have a written guide to follow.  I am most sure, however, that very, very few would have a debriefing.

In case you are having trouble with the Dutch, here's a translation of the debriefing elements:
Results versus plan. 
Execution: What went well. What went less well. What will we do differently next time. 
Summary by leader.

If we are to adopt the scientific method in clinical care improvement, a real-time review of the effectiveness of reducing variation is essential.  How otherwise to evaluate whether the protocol was effective and to decide if it should be modified?

Joris is honest about the progress of this effort in his PICU.  He notes improvement and general compliance with the approach and procedures, but he also notes lapses.  For instance, sometimes the leader will forget to conduct the debriefing.  That's all right, but not if the other crew members forget to remind him/her when it happens.  A tenet of CRM is mutual responsibility and authority:  If the chief forgets to carry out part of the protocol, the others are required to point this out.

Why did Joris devote his personal time and energy to implementation of CRM in his intensive care unit?  He explains that he once gave the wrong instructions to a nurse, who followed them blindly, with almost disastrous results for a patient.  Later, when he and she talked about the case, she said, "If it had been a resident, I would have questioned the order.  But you are a senior doctor, and I therefore hesitated to question you."  It was at that moment that Joris realized that even the best doctors need protection from their own errors.  Every person in the clinical setting needs to understand that he or she has the responsibility and authority to express concern if things appear to be going awry.

As Sully mentions, CRM is "a compact, with defined goals and responsibilities. These are not soft skills. They are human skills. They have the potential to save more lives than new medical technologies."


Rob Fraser MN RN said...

Thanks for sharing Paul. Definitely an interesting approach. I wondering how this eventually gets carried over into less critical settings. As a new nurse and someone that has worked in educational settings with students there are lots of times within nursing teams I can see this approach being useful.

There are times that a simple catheterization does not go well. Although it is unlikely to have immediate negative consequences there is a lot of potential for infection. It would be helpful for the learner to have these sort of organized approach, with a briefing and debriefing.

On the other hand I worry about the challenge of documentation and completing all these requirements when as teams we are all time constrained. Although documentation as close to time of care is ideal often we complete it hours after delivering care, I wonder what the negative side of implementation of more documentation can be. Since we are further distracted from care by since it happens hours afterwards and is only being completed to be filed.

Thanks as always for sharing your thoughts.

Paul Levy said...

This is not documentation, Rob. This is the protocol. Following a standardized approach tends to save time, not take more time.

L. Frijns (PICU fellow to dr. Lemson) said...

True, what is shown is the front and the back of the laminated protocol sheet. Versions adapted to the most common procedures (intubation, central line insertion, chest drain insertion, etc) are kept in each patient room and are ready to use whenever required. There's no documentation as such involved, a team member reads out loud from the laminated sheet to other team members. Not only is it a checklist, but the mere act of reading it out focuses the team to the procedure they are about to carry out.

Anonymous said...

I might add a comment to the concerns about documentation. Documentation has taken over medicine mainly because it is necessary to get paid under the current system. Just imagine a system where one no longer has to document all the steps because they are reliably performed in every hospital as a matter of course. The current payment system is nothing more than a reaction to the current chaotic 'system' of medical care delivery. We must keep our eyes on the ball of where we are trying to go, and why.

nonlocal MD