Crisis Resource Management Principles by Dr. Catherine Allan.
After viewing this video, the learner should be able to describe the five principles of
crisis resource management, discuss the responsibilities of an effective Event Manager
during resuscitation, and identify the role of teamwork during resuscitation.
Effective resuscitation of a patient during cardiac arrest or a crisis situation requires
a team that can quickly make a correct diagnosis and carry out the right treatment strategies
in a timely manner.
A combination of the right medical knowledge and technical skills must be applied.
However, these things alone are not enough for a safe, efficient, and successful resuscitation.
Rather, individuals with varying knowledge and technical skills must come together to
rapidly form a team that works seamlessly together to provide care to the patient.
The teamwork skills required to do this have been well-defined, are as critical as the
clinical skills, and just like technical skills, require practice.
These skills have been described under the umbrella of crisis resource management principles.
There are five major principles of crisis resource management-- role clarity, communication,
personnel support, resource utilization, and global assessment.
In the video that follows of a simulated resuscitation, you will see a team applying each of these
five principles.
Role clarity refers to the idea that each person assumes specific responsibilities during
a resuscitation and clearly identifies to the team what task or role they are taking
on.
All members of the team are responsible for establishing role clarity.
The Event Manager will assign certain tasks.
For instance, Sarah, can you take over the airway?
And team members will articulate they are accepting those roles.
Similarly, if a team member identifies a task that is not being performed, they may volunteer
to fill that role with a declaration to the Event Manager and the team at large.
"I'll be the recorder."
By explicitly identifying specific individuals to take on each task, the team can avoid tasks
being neglected or duplicated.
Of particular importance is the establishment of a clear Event Manager.
The Event Manager is responsible for coordinating and setting direction for the whole team during
the resuscitation.
The Event Manager can use several specific strategies to coordinate the team.
First, the Event Manager can frequently update the team on the progress of resuscitation
and next steps with simple statements such as, "This is a three-month-old, intubated
for respiratory failure, with bronchiolitis, who now has acute hypoxemia, not responsive
to increased oxygen.
Possible causes include a plugged or dislodged endotracheal tube, bronchospasm, and a pneumothorax."
This simple statement helps establish a shared mental model among team members.
It also allows other team members to contribute knowledge that will help the Event Manager
and the team come to the correct diagnosis.
For instance, after such a statement, a respiratory therapist might offer, "I'm having difficulty
moving the chest with hand ventilation, and I don't have an end tidal waveform.
I think this is a blocked ET tube."
Individual team members may hold key pieces of information that will help the team make
an accurate diagnosis or treatment plan.
The most effective Event Managers will empower team members to share information with simple
statements such as, "Is there anything else I'm missing?" or, "Does anyone else have any
ideas?
Please speak up at any time if you do."
The Event Manager must maintain awareness of what is going on in all aspects of resuscitation
at all times.
To do this, they should avoid engaging in hands-on tasks, such as intubation or line
placement, that may lead to fixation and limit their attention to other aspects of the resuscitation.
If the Event Manager must perform a task, the Event Manager role should temporarily
be transitioned to another individual.
Several key principles of communication are essential to effective team function.
First, communication should be directed toward specific individuals.
For example, "Jen, could you please send a blood gas?"
Such communication should be followed by a closed-loop response-- "yes, I'll get that
blood gas--" and ideally by a follow-up when a task is completed.
"The blood gas has now been sent."
This signals to the Event Manager that, one, the task assignment has been heard and is
being carried out and, two, the task is now complete.
The Event Manager carries a high cognitive load during the resuscitation.
By explicitly transferring some responsibility to other team members, the Event Manager can
use less mental capacity tracking whether specific tasks are getting done and more energy
identifying problems and critical next steps in the resuscitation.
Closed-loop communication, as described, also helps prevent tasks from getting dropped because
everyone thinks someone else is doing the job.
Personnel support refers to the idea that you need to have the people who have the right
knowledge and skills to resuscitate the patient.
Outside of the standard members of a resuscitation team, the team should anticipate what other
personnel might be required to mobilize these individuals early to avoid delays in care.
Examples might include an anesthesiologist or otolaryngologist if a difficult airway
is encountered or a surgeon if ECMO might be needed.
Similarly, resource utilization is all about anticipating equipment or other resources
that might be needed and getting them in place early to avoid delays.
The last of the five principles of crisis resource management, global assessment, is
undoubtedly one of the most important.
Sometimes referred to as maintaining the 50,000-foot view, this term refers to the concept that
while the team is carrying out the specific steps of resuscitation, often according to
specific algorithms, that they must not lose sight of the big picture.
The Event Manager in particular must maintain the big picture view.
But the whole team contributes.
This is what allows the team to consider a differential diagnosis for the patient's deterioration
and avoid errors of fixation.
The Event Manager helps create a shared mental model for the team by providing frequent updates
to the team not just about resuscitation tasks, but about overall progress of the resuscitation.
For instance, "It looks like, based on difficulty bagging and no end tidal CO2, that the patient
has an obstructed endotracheal tube.
We're going to pull the ET tube and try bag mask ventilation.
We'll need to get prepared to reintubate."
This sort of statement allows the whole team to anticipate what is coming next, allowing
individuals to begin to prepare equipment and resources that will be needed in subsequent
steps.
All team members can be important contributors to global assessment.
Event Managers should actively invite all team members to speak up and contribute knowledge
or observations.
Given the high cognitive load for the Event Manager during a resuscitation, there's a
high likelihood that another team member will identify a key change or problem before the
Event Manager.
Also, other members of the team may have critical information about the patient that the Event
Manager is not aware of.
For instance, the child's bedside nurse, who spent hours at the bedside with the child,
often holds critical pieces of the puzzle.
The entire team should be empowered to make suggestions to the Event Manager to help the
team come to the correct diagnosis and treatment plan and to help avoid errors of fixation.
In the following video, you will see a team carrying out a simulated resuscitation of
a critically ill infant.
This is not a scripted resuscitation.
The team has been given a small amount of background information about the child and
has then been called in to respond to an emergency.
You will see this team utilize many of the principles of crisis resource management to
organize themselves and effectively care for this patient.
You may also identify areas where these principles could have been applied more effectively.
Just like technical skills, teamwork skills required practice.
Hey, Jen.
Hey, Sonia. What's going on?
Nothing. How are you doing?
Good. How are you?
Good.
Would you mind just seeing if we can suction?
Yeah, absolutely.
I don't have a great lung sounds.
Sure, I'll call respiratory too.
OK.
Well, I think I'll just start to bag.
Thank you.
This is the unrepaired tet (Tetralogy of Fallot).
Yes, unrepaired tet.
Hey, Steph.
So this is the unrepaired tet.
I just listened, didn't have great lung sound.
Sounds almost like squeaky, coarse, but also not well.
Airway different both sides?
It's been difficult to bag.
I was going to try suctioning.
Yeah, he's really hard to bag.
I'll give Patrick and Lindsay a call.
Yes, that would be great. Thank you so much.
Do you want to listen?
Yeah.
Can you bag for just a second while I listen?
Yeah.
You don't mind pulling this, do you?
There we go.
Hi, Sonia.
Hey, I'm not hearing very good breath sounds…
… I’m not hearing very good breath sounds-- So I didn't hear great breath sounds.
Initially our stats were OK.
This is the pre-opt tet.
And then we started getting more desaturated.
I was going to see if there was something that we could suction out as far as a plug,
but we're just progressively getting more desaturated.
I'm going to make a pass.
I'm just going to take that.
Is there anything you need from me?
Can I get you anything right now, Sonia?
So I can't make a pass.
Can't make a pass.
Cannot make a pass.
No.
OK.
So I think that we're going to work under the assumption that his endotracheal tube
is blocked.
So why don't we get some more sedation for him?
And let's get Steph to reintubate.
Let's get the rest of the team in here.
Let's call the attending-- I'm going to pull this tube because I'm not
getting-- And the charge nurse.
Do we have a mask?
We have a mask.
You can go ahead and hit the button.
OK, here's Fentanyl and vec (vecuronium).
Can we get the head of the bed down?
OK, yeah.
Move the bed down.
We still have a heart rate, still have an OK blood pressure for the moment.
Your heart rate's dropping right now.
I have Fentanyl and vec right here.
Yeah.
So what happened was--
Why don't we get the cart ready?
--they were suctioning.
Trish, if you could be ready to document if it becomes necessary.
I'm going to give a dose of morphine.
Yeah, [INAUDIBLE] morphine.
[INTERPOSING VOICES] If anything changes, we'll have you--
It looks like there's something in it.
--assist at the bed with compression or anything else they would need.
Desaturated but still not getting clean air entries.
That's OK, just wait.
Very hard to pass.
4.5 kilos is the patient's weight.
Thank you.
We're getting better chest wall movement now that we've pulled endotracheal tube.
I just gave a dose of fentanyl.
I have a dose of paralytic too.
Can we get a 4-0 endotracheal tube?
Yeah.
So just from where I'm standing, then it looks like primary desaturation or primary-- what
was the problem first?
Primary desaturation.
But when I listened, I couldn't hear good breath sounds to begin with.
OK. Either side?
Both.
Ok, and her heart rate's starting to fall now.
Could we get the board?
And set's still falling.
Let me get out of your way.
Dr. Alexander, to organize the room real quick.
Sonia's at the bed side.
I'm in charge.
Jason can begin the compressions if necessary now.
OK, thank you very much.
I just gave a dose of fentanyl.
Would you like me give paralytic just to take him out of the picture?
Oh, yes please.
So you've got roc.
I gave vec.
OK, good.
So one per kilo of vec in.
How much fentanyl?
I gave my 5 per kilo of fentanyl.
OK, thank you.
So you're beginning to drop around, correct, and anything else they would need to prepare
for intubation.
They have given sedation, and they have given vec.
So they should this fine with those drugs a while to focus on a round of [INAUDIBLE].
And so our blood pressure's also a little bit low.
Do you want to give a dose of epi, just 1 per kilo for now, to bring the blood pressure
up?
1 kilo of fentanyl right now.
Do you have a dose of epinephrine?
Sure.
So just give 1 per kilo of epinephrine for now please and maybe some calcium if you've
got it.
OK.
Sarah, can I have a dose of calcium too with that epi, please?
Sure.
And technically it's bradycardia, so we could use--
We still have good pulses.
Do you want me to start compressions?
Her blood pressure's fallen since I last looked.
I think we probably should start preparing if you don't mind.
And Lindsay, are you preparing to intubation?
Trish, we're starting compressions.
Yes. I asked for a 4-0 endotracheal tube, which was in place prior a Miller 1 blade, a stylet,
and some lube.
This is 1 micro kilo of epi.
So now that we are doing CPR-- You want to cover those.
-- we did cover those.
I beg your pardon, I'm sorry.
That's OK.
So this is 10 mikes per kilo of epi.
Lindsay's asked for intubation equipment.
Has anyone got?
I have intubation equipment.
I just need to yank our suction now.
OK.
I gave a co dose of epi.
And we're doing CPR on a pre-op cardiac patient.
We should let the ECMO and the cardiac surgical teams know please.
We'll have them paged.
Do you have the epi, or do you want the epi?
I have epi. Thank you.
Shehzadi, could you made me a long line please?
A long line?
Yeah.
So guys, just to summarize where we're up to now is we've had a primary hypoxic event,
and we deteriorated into effectively PEA, or sinus bradycardia, not responded to epinephrine,
and we're doing CPR.
We don't have a secured airway in, so our next step is going to be to secure the airway,
which Lindsay is preparing to do at that end.
Is there anything, that I'm not thinking of, that you guys are thinking of?
Not at the moment unless you want to consider bicarb instead of doing compressions on them?
Let's get-- let's keep bicarb in mind in two minutes time, but I think for now, we'll try
and correct the hypoxemia and get the rhythm back.
We have a dose of bicarb and calcium at bedside and another dose of fentanyl.
Thank you.
So along the way, I know I asked for a lot of things altogether.
I asked for fentanyl, vecuronium, and calcium, and epi.
Were all those things given?
No, I have given fentanyl, and a dose of vecuronium, and then I gave a co-dose of epinephrine.
And that was it.
OK, so no calcium at this stage.
Now that we're doing CPR, I would not do that.
At the point that you guys are ready, I would be comfortable with you looking to reintubate
and in a usual downtime phase of CPR.
Could we get the end tidal please from a CO cart?
Patrick, could I get the end tidal from the CO cart please?
Yeah.
Can we get the end tidal down?
Sure.
And then Shehzadi, as they're preparing to intubate, would you swap with Jason as a compressor?
Mhm.
Thank you.
So at the time that I first listened to breath sounds, it sounded like there were breath
sounds on both sides to me.
Was that how it sounded you as well?
So the chest wasn't moving, and we were not getting air entry when I--
With the tube in?
To listen with the tube in.
When we pulled the tube, I came to help with bag-mask ventilation.
I didn't listen, but I saw a chest rise.
OK, great.
Jason, are you ready?
All right, the next breath.
So at the next breath, perhaps you can tag in with Shehzadi.
OK, do the compressions please.
You want to do a-- so I do have a pulse.
So the rhythm is on his bradycardia.
Can I get a little bit of Cricort? I have epiglottis.
Sure.
But I don't have a great view of the cords.
Trish, will let us know when it's been time since we've given the last dose of epi?
We saw the tube pass through the cords.
Thank you.
So that is good chest rise and fall.
And we're just looking for an end tidal there.
End tidal is coming.
There we go.
Great, sorry Shehzadi, thank you.
Her heart rate's still only 40 though, so you should probably go back to doing chest compressions.
Sorry, Shehzadi. I was hoping that might come up.
And how long has it been since we gave epi?
How deep are you?
Three minutes.
Three minutes?
So we could give another dose of epi at this stage please.
I have that coming right now.
And 100 times a minute please, Shehzadi, for the--
10mgs per kilo of epi.
Thank you.
Trish, I'm giving that co dose of epi. it's 10 mgs per kilo.
So it looks like our rhythm's changed.
You should keep going, Shehzadi, for now unless the patient show signs of life, which will
be hard since we have muscle relaxed her.
But just looking at the monitor, we've certainly got an improved organized rhythm.
That looks sinus although sinus-brady.
And our stats have improved since intubation ventilation, and the blood pressure is improved.
So at the two-minute mark, I'll get you to stop, Shehzadi.
Shehzadi, let me know if you need to change.
OK.
And Sarah, can I get some ET tube tape please?
Sure.
OK.
Why don't you stop for now for a sec, and I'll do a rhythm check.
OK, so I've got a good pulse.
We're deoxygenated, but we've got adequate blood pressure.
Let's get the tube secured.
And at that point, we can look at-- have you got norepi or phenylephrine in line?
I do not have either one of those.
We can have those made.
OK, so let's keep those.
Let's get those ready to go, but it looks like our stats have actually improved as well.
Thanks for watching this video about crisis resource management skills.
The team you just watched performed a simulated resuscitation using techniques such as closed-loop
communication, frequent updates on tasks, and clear assignment of roles.
There was a clear Event Manager who directed the resuscitation and organized the team while
inviting and accepting input from all team members.
These skills require practice as a team but, once mastered, can significantly improve the
way a team performs a resuscitation.
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