Crew Resource Management in ICUs

Marck Haerkens and colleagues have published an important article: "Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study." If you are trying to institute sustained clinical process improvement and/or high reliability in your hospital, it is worth a read.

The full text is available here, for free. Here's the introduction:

To err is human. As a result, everything that a human being devises, uses, or does is prone to error and failure. Human factors refer to environmental, organizational and job factors, and to human and individual characteristics which influence professional behavior in a way that affects performance and safety. Human factors account for the majority of adverse events in aviation. Human factors awareness training entitled ‘Crew Resource Management’ (CRM) was introduced in 1979 for aircrew after a series of accidents in which human factors were found to be the root cause. Following the implementation of CRM, a decrease in events led to CRM becoming the present day aviation operational standard.  Especially during time critical cockpit emergencies, CRM is considered vital for aircrew effectiveness, although sound scientific proof of CRM effectiveness in aviation is lacking.

In clinical medicine, human factor-related errors can have a major impact on patient safety. This is especially so in departments where high risk, time critical procedures on vulnerable patients are performed in a multidisciplinary team setting; human factors are likely to play an important role. Indeed, in critically ill patients, the occurrence of complications is related to outcome.

The defining aspect of CRM is a system approach to safety culture. Rather than focusing on individual failure, CRM aims to identify system flaws and uses standardized communication tools to improve process effectiveness and safety. The message of “good people are set up to fail in bad systems – let's figure out how to keep everyone safe” is more easily accepted than “you have a problem that needs to be corrected.”  This approach is fundamentally different from conventional quality and safety programs in medicine that focus on limiting variation in human behavior through regulations, or scenario-based team training, when these are not embedded in the more broad CRM approach. Contrary to aviation, there is currently no international standard for medical CRM training.

While the parallels between the critical processes in aviation and medicine suggest that a well-adapted medical CRM training may have potential to improve patient safety, evidence of the effects of CRM on patient outcome in a clinical setting is limited. Closed format intensive care units (ICUs) facilitate both CRM implementation and effect evaluation. The aim of this study was to assess the effects of CRM implementation on outcome in critically ill patients.

Excerpts from the abstract:

We performed a prospective 3-year cohort study in a 32-bed ICU, admitting 2500–3000 patients yearly. At the end of the baseline year, all personnel received CRM training, followed by 1 year of implementation. The third year was defined as the clinical effect year. All 7271 patients admitted to the ICU in the study period were included.

The primary outcome measure was ICU complication rate. Secondary outcome measures were ICU and hospital length of stay, and standardized mortality ratio.

Our data indicate an association between CRM implementation and reduction in serious complications and lower mortality in critically ill patients.