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June 30, 2015

Benefits of applying CRM to cardiac arrest resuscitation

Historically, emergency training for EMS personnel primarily focused on individual acquisition and mastering of discrete technical skills. These include basic and advanced airway management techniques, CPR, IV access and medication administration. Educators and even system administrators often did not focus on the behavioral and communication skills necessary for medical personnel to effectively provide emergency care in the realities of a dynamic team-based environment.

While courses such as International Trauma Life Support (ITLS) or Advanced Cardiac Life Support (ACLS) mention the importance of teamwork, the primary value of these courses is in ensuring each attendee has attained baseline knowledge about a specific critical event. In fact, direct observation of team performance under actual clinical conditions suggests these courses do little to prepare an individual for a leadership role within the team.[1]

Poor leadership leads to poor outcomes

Often the major obstacles to effective management of cardiac arrest are not lack of knowledge about the treatment algorithms but rather poor leadership and the lack of explicit task distribution during the resuscitation attempt.[2] An emergency department evaluation of a trauma team found the presence of clear leadership led to improved treatment guideline adherence and earlier development of a definitive treatment plan.[3]

Effective teamwork does not automatically happen simply because a group of emergency responders arrive on the scene of a medical emergency.[4] “Outer-loop,” or non-team-leader-initiated communication is common during a resuscitation attempt and has the potential to be distracting for the team leader as well as other non-participating members.[5] Successful teams are composed of responders who understand the roles and responsibilities of every other member.[6] These teams are trained to cooperate and reduce conflict.

Airlines and EMS

Recently, experts have turned to a concept known as crew resource management (CRM) to address the non-technical skills necessary for critical care teamwork.[7] These non-technical skills include communication, teamwork, and leadership.[8] CRM originates from attempts in the late 1970s to make air travel safer.[9] Reports from the time found dangerous flying conditions often resulted from communication or social skill failures of the flight crew rather than a lack of technical knowledge. Unfortunately, these failures in many cases resulted in the loss of lives.

Simulation helps build teamwork

One component of crew resource management training is the use of simulation. Through even simple and inexpensive forms of simulation, educators and training officers can recreate many of the conditions that may have interfered with a rescue team’s ability to effectively manage a critical event. Arguably, the greatest value of simulation in resuscitation training lies in the repeated exposure of the rescue team to those conditions in a safe environment until the team can perfect an action, a procedure or a conversation.[10]

Following the simulation exercise, the rescue team must engage in a debriefing session during which each team member has the opportunity to critically examine every aspect of the exercise and learn where errors occurred. Team members can then suggest solutions to prevent the breakdown from occurring again. Without debriefing, simulation is generally ineffective as team members are not aware of their mistakes and may continue to perform the same incorrect actions or continue to engage in ineffective communication patterns.

Simulation exercises and targeted resuscitation training translate into improvements in clinical performance. A case-controlled study of in-hospital cardiac arrest found internal medicine residents trained on a human patient simulator showed significantly higher adherence toACLS standards than residents trained without the simulator.[11] Cardiac arrest teams receiving pit-crew resuscitation training significantly reduced the no-flow rate during the first 10 minutes of the resuscitation attempt in the emergency department.[12] Although not sufficiently powered to detect a change, the reduction in no-flow rate trended toward improved survival outcomes.

Improved outcomes through pit-crew training

EMS agencies implementing pit-crew resuscitation training report doubling survival rates over historical controls.[13] Other systems report higher neurologically intact survival rates compared to the national average after implementing a system-tailored pit crew resuscitation model.[14]

Tailored pit crew training provides an opportunity for many EMS systems to improve survival following out-of-hospital cardiac arrest. This type of training integrates evidence-based medicine with crew resource management principles to improve team dynamics and patient care delivery.

References

1. Cooper, S., & Wakelam, A. (1999). Leadership of resuscitation teams: ‘Lighthouse leadership’. Resuscitation, 42(1),27–45. doi:10.1016/S0300-9572(99)00080-5

2. Marsch, S., Muller, C., Marquadt, K., Conrad, G., Tschan, F., & Hunziker, P. R. (2004). Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation, 60(1), 51–56. doi:10.1016/j.resuscitation.2003.08.004

3. Hoff, W., Reilly, P., Rotondo, M., DiGiacomo, J. C., & Schwab, C. W. (1997). The importance of the command-physician in trauma resuscitation. Journal of Trauma, 43(5), 772–777.

4. Salas, E., Sims, D. E., Klein, C., & Burke, C. S. (2003). Can teamwork enhance patient safety? Forum Risk Manage Foundation Harvard Medical Institutions, 23, 5-9.

5. Taylor, K. L., Ferri, S., Yavorska, T., Everett, T., & Parshuram, C. (2014). A description of communication patterns during CPR in ICU. Resuscitation, 85(10), 1342-1347. doi: 10.1016/j.resuscitation.2014.06.027

6. Oandasan, I., Baker, G., Barker, K., Bosco, C., D’Amour, D., Jones, L., Kimpton, S., Lemieux-Charles, L., Nasmith, L., San Martin Rodriguez, L., Tepper, J., & Way, D. (2006). Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada. Retrieved from http://www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/CommissionedResearch/teamwork-synthesis-report_e.pdf

7. Flin, R., & Maran, N. (2004). Identifying and training non-technical skills for teams in acute medicine. Quality and Safety in Health Care, 13 (Suppl 1), i80–i84. doi:10.1136/qshc.2004.009993

8. Briggs, A., Raja, A. S., Joyce, M. F., Yule, S. J., Jiang, W., Lipsitz, S. R., & Havens, J. M. (2015). The role of nontechnical skills in simulated trauma resuscitation. Journal of Surgical Education, 72(4), 732-739. doi: 10.1016/j.jsurg.2015.01.020

9. Fisher, J., Phillips, E., & Mather, J. (2000). Does crew resource management training work? Air Medical Journal, 19(4), 137–139. doi:10.1016/S1067-991X(00)90006-3

10. Hunt, E., Shilkofski, N., Stavroudis, T., & Nelson, K. (2007). Simulation: Translation to improved team performance. Anesthesiology Clinics, 25(2), 301-319. doi:10.1016/j.anclin.2007.03.004

11. Wayne, D. B., Didwania, A., Feinglass, J., Fudala, M. J., Barsuk, J. H., & McGaghie, W. C. (2008). Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest, 133(1), 56–61.

12. Ong, M. E., Quah, J. L., Annathurai, A., Noor, N. M., Koh, Z. X., Tan, K. B., Pothiawala, S., Poh, A. H., Loy, C. K., & Fook-Chong, S. (2013). Improving the quality of cardiopulmonary resuscitation by training dedicated cardiac arrest teams incorporating a mechanical load-distributing device at the emergency department. Resuscitation, 84(4), 508-514. doi:10.1016/j.resuscitation.2012.07.033

13. Glendenning, D. (2012). Putting the pit crew approach into practice. EMS World, 41(11), 41-47.

14. Braithwaite, S., Friesen, J. E., Hadley, S., Kohls, D., Hinchey, P. R., Prather, M., Karonika, M., Myers, B., Holland, W. D. 2nd., Eason, C. M., & Carhart J. (2014, Nov.). A tale of three successful EMS systems. How coordinated “pit crew” procedures have helped improve cardiac arrest resuscitations in the field. Journal of the Emergency Medical Services, Suppl, 28-35.

About the Author

Kenny Navarro is an Assistant Professor in the Department of Emergency Medicine at the University of Texas Southwestern Medical School at Dallas. He also serves as the AHA Training Center Coordinator for Tarrant County College. Mr. Navarro serves as an Emergency Cardiovascular Care Content Consultant for the American Heart Association, served on two education subcommittees for NIH-funded research projects, as the Coordinator for the National EMS Education Standards Project, and as an expert writer for the National EMS Education Standards Implementation Team. Send correspondence concerning any articles in this section to Kenneth W. Navarro, The University of Texas Southwestern Medical School at Dallas, 5323 Harry Hines Blvd MC 8890, Dallas, Texas 75390-8890, or e-mail kenny.navarro@ems1.com.
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