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Crew Resource Management in the ED

16 May, 12 | by Janos P Baombe, Web Editor

The brave new world of major trauma centres (MTCs) is here; most Emergency Departments (EDs) are planning for them, be it reassurance (and relief?) for smaller ones as trauma patients are whisked off to the local MTC, or the increased workload for the new MTCs as ambulances head to their doors.

Changes of this nature mean a change in team dynamics; the increased work for MTCs means there will be a focus on the trauma team – a varied group of staff that meets in moments of intense pressure to deliver advanced care to the sickest patients the hospital will see.

Are we a different animal from other professions that find themselves in comparable situations? If not, why do these other professions (e.g. nuclear plant workers, fire and rescue personnel and airline cockpit crew) continuously practice, simulate, brief and debrief incidents whereas trauma teams rarely, if ever, do?

Crew Resource Management (CRM) is creeping into clinical practice and, despite the cynicism of skeptics, it is having a positive impact. The ability of individuals to work as part of a team, and for that team to then work as an efficient single entity in a reliable and reproducible way, must be the goal of ED teams and CRM offers simple and logical ways to support this.

The principle behind CRM is good communication and decision-making. Clinicians’ decisions are often opinions based on personal experience and the immediate information available at the bedside. In the early stages of trauma management accurate information is limited, and to some extent decisions are educated guesses. Better quality background information reduces the degree of guesswork and this can be gained through open communication.

A team leader who briefs the team and introduces its members to each other before the patient arrives opens communication streams and allows team members to input to decision-making. The same team leader who then stands back, maintains situational awareness, observes the team at work, watches and listens, conscious of the ticking clock above the trolley will quietly allow the team to perform their individual specialist roles whilst ensuring that care is swift and targeted.

The role of CRM in aviation is illustrated by two events. When a twin engine British Midland 737 crashed near East Midlands Airport in 1989 killing 47 passengers there were significant failings in communication and decision making after a single engine malfunction led to the healthy engine being shut down before landing. In contrast, when a twin engine US Airways Airbus 320 landed in the New York Hudson River in 2009 following a bird strike and total power loss and with no deaths, there was a near perfect allocation of tasks, communications, decision making and activation of pre-briefed emergency drills.

The different outcomes in these two situations were in some considerable part due to CRM.

Why should teamwork in healthcare not be to the same standard?


Nick Crombie


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  • CRM is aviation an industry specific concept that has been honed and developed over 50 + years, and whilst tempting to draw analogies with medicine, it should not be transposed into Emergency Departments or trauma centers directly.  There are innumerable differences between airline crews and workspace compared to hospital resuscitation rooms.  One example is “pre-flight brefings”. Whilst ideal they are nearly always impossible in ED settings, where individuals arrive before, during and even after the resuscitation. The word “team” is a misnomer as well.  Manchester United is a team. Formula One pit crews are teams.  Teams practice together, know each others strengths and weaknesses and are coached, managed and drilled together to perfect their skills.  A heterogenous group of strangers who arrive in an ED to manage a trauma is not a team.  Whilst some human factors elements like situational awareness are useful in medicine, we should be careful not to see CRM as the only solution to optimising resuscitation management.  Teaching ED and trauma doctors how to manage multiple simultaneous tasks that are proceeding at different rates, prioritization skills, communication skills and conflict resolution, as well as inter-disciplinary simulation practice would be far more helpful.

    Dr Andy Buck
    Emergency Physician
    Melbourne Australia

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