Thursday, November 15, 2012

CRM in intensive care settings

The use of Crew Resource Management is well known in areas like airline cockpits.  CRM, when properly implemented, maintains certain aspects of the hierarchy that is required in a command situation, but it also empowers all members of the crew to behave in a way that satisfies safety and quality concerns--even if the pilot is failing to do his or her job correctly.  An article by Haerkens, Jenkins, and van der Hoeven in the Annals of Intensive Care provides support for the proposition that CRM might make a difference in clinical settings.  No subscription is required (yay!), so please read it here.

I like some of the observations:

The majority of current interventions focus on implementing safety tools such as event-reporting systems, quality and safety dashboards, evidence-based guidelines and checklists. Even though the results of a comprehensive unit-based safety program (CUSP) are promising, introducing more stringent rules potentially increases the gap between procedure and practice. Therefore, the question remains if these tools can be truly effective in the traditional hospital climate, where highly trained professionals tend to focus more on individual performance than team effectiveness. Moreover, the typical culture in which junior members of the ICU staff should not question the decisions made by senior members adds to the challenge.

ICUs with a “team-oriented culture” have shorter lengths of stay, lower nursing turnover, higher quality of care and can better meet family members’ needs.

Human Factors account for the majority of adverse events in aviation as well as in clinical medicine. The current safety paradigm is still based on ways to limit human variability in otherwise safe systems, promoting stringent procedural guidelines. CRM focuses on improving interprofessional cooperation and team performance and thus patient safety. Even though evidence of CRM on medical errors and patient outcome is still scarce, the parallels between the critical processes in aviation and Intensive Care suggest that a well-adapted medical CRM training has potential for the ICU environment too. 


Anonymous said...

There are two critical statements in the article:

"By now CRM training is mandatory for professional aircrew in Europe and the USA." and;

"Any CRM-training has to meet Federal Aviation Authority (FAA) or Joint Aviation Authority (JAR) regulations. Not only do they define the various subjects but also the extent to which each subject should be discussed and set limits for refresher training. This standardization is a major contributing factor to the success of CRM."

The third critical difference is that air crews are at personal risk of death from an accident, unlike medical professionals. Thus, as the authors point out, any sort of such training under current conditions is likely to be regarded as optional and/or as a pain in the tush. We didn't see the aviation industry spend years arguing over the effectiveness of CRM training after Tenerife, did we - they just did it. Until we have some sort of overarching oversight board with mandate authority such as the FAA or NTSB (I prefer both), progress will be measured in years or decades, despite numerous earnest attempts to improve safety.

nonlocal MD

Anonymous said...

Do I get the feeling nonlocalMD is recommending an "eye for an eye" approach to medical safety issues? ;)

Anonymous said...

Not at all, anon. But think about what kind of air safety system we would have if all the airlines were left to their own devices on safety, each one inventing their own way to deal with it - or not dealing with it at all because they don't think they have a problem. Would you want to fly under that circumstance? That is what we are asking patients to survive when they enter the hospital. I am simply saying that we can't continue to wait for each hospital to individually get its act together. It just simply won't happen in our lifetimes, absent some sort of coordination and mandate.