Crisis Resource Management

Category: Others/ Misc

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Crisis Resource Management : 

Crisis Resource Management

Crisis Resource Management : 

Crisis Resource Management Ability, during an emergency, to translate knowledge of what needs to be done into effective real world activity

Resources : 

Resources Self Other personnel on scene Equipment Cognitive aids (checklists, manuals) External resources

Incident Management Process : 

Incident Management Process

Self-Management : 


Core Cycle : 

Core Cycle Observation Action Decision Reevaluation

Observation : 

Observation Human close attention is limited to one or two items “Supervisory Control” must decide: What information to attend to How to observe it

Observation : 

Observation Errors Not observing Not observing frequently enough Not observing optimum data stream

Observation : 

Observation Causes of Errors Lack of vigilance (ability to sustain attention) Failure to attend to all relevant information Information overload

Verification : 

Verification A change is observed Is it: Significant? An artifact (false data)? A transient (true data--short duration)?

Verification : 

Verification Repeat observation Observe a redundant channel Correlate multiple related variables (P, BP) Activate a new monitoring modality Recalibrate instrument/test its function Replace instrument with back-up Ask for a second opinion

Problem Recognition : 

Problem Recognition Do observations indicate problem? What is its nature, importance? A common error is to observe problem signs but fail to recognize them as problematic

Problem Recognition : 

Problem Recognition Do cues observed match pattern known to represent a specific problem? Yes?--Apply solution for that problem No?--Apply heuristic (rule of thumb)

Heuristics : 

Heuristics Generic Problems “Too Fast, Too Slow, Absent” “Difficulty with Ventilation” “Inadequate Oxygenation” “Hypoperfusion” Generic Problems Allow Use of Generic Solutions to Buy Time

Heuristics : 

Heuristics Frequency gambling “If it eats hay and has hoofs, it’s probably a horse, not a zebra.”

Heuristics : 

Heuristics Similarity matching The situation more or less resembles one I’ve handled before Therefore, I’ll proceed like it is the same

Dangers of Heuristics : 

Dangers of Heuristics By definition, don’t always work Ignore some information that is present Yield adequate, but not optimal decisions

Advantages of Heuristics : 

Advantages of Heuristics A good solution applied now may be better than a perfect solution applied later For example, after the patient is dead!

Prediction of Future States : 

Prediction of Future States What will probably happen if…? Influences priority given to problems Common errors Failure to predict evolution of a catastrophe Failure to assign correct priorities during action planning

Action Planning : 

Action Planning

Precompiled Responses : 

Precompiled Responses Cue trigger predetermined/structured responses Allow for quick solutions to problems Can fail if problem: Is not due to suspected cause Does not respond to usual treatment

Abstract Reasoning : 

Abstract Reasoning Essential when standard approaches not succeeding Can involve: Searching for high level analogies Deductive reasoning from deep knowledge base Can be time-consuming

Action Implementation : 

Action Implementation Sequencing Actions must be prioritized, interleaved with concurrent activities Considerations: Preconditions Constraints Side effects Rapidity and ease Certainty of success Reversibility Cost in attention/resources

Action Implementation : 

Action Implementation Workload Management Strategies Distributing work over time: Pre-loading Off-loading Multiplexing Distributing work over resources Changing nature of task (altering standards of performance)

Action Implementation : 

Action Implementation Mental simulation of actions can help identify hidden flaws in plans If I do what I plan to do, what is going to happen? Will it work? Will it work, but will it create or complicate another problem?

Reevaluation : 

Reevaluation Did action have an effect? Is problem getting better or worse? Any side effects? Any problems we missed before? Was initial assessment/diagnosis correct?

Reevaluation : 

Reevaluation Essential to preventing “Fixation Errors”

Fixation Errors : 

Fixation Errors “This And Only This” Failure to revise plan, diagnosis despite evidence to contrary

Fixation Errors : 

Fixation Errors “Everything But This” Failure to commit to definitive treatment of major problem

Fixation Errors : 

Fixation Errors “Everything’s OK” Belief there is no problem in spite of evidence there is

Fixation Errors : 

Fixation Errors “If everything is going so well, why isn’t the patient getting better?”

Team Management : 

Team Management

Effective Team Decision-Making : 

Effective Team Decision-Making Situation Awareness Metacognition Shared Mental Models Resource Management

Situation Awareness : 

Situation Awareness Recognizing decision must be made or action must be taken Notice cues Appreciate significance What is risk? Do we act now? Do we watch, wait? Are things going to deteriorate in future?

Metacognition : 

Metacognition Determining overall plan, information needed to make decision Thinking about thinking Being reflective about: What you’re trying to do How to do it What additional information is needed What results are likely to be

Metacognition : 

Metacognition Stop and think If we do this (or don’t do it) what is likely to happen? When is a decision good enough?

Metacognition : 

Metacognition Teams that generate more contingency plans make fewer operational errors Effective teams emphasize strategies that kept options open Effective teams are sensitive to all sources of information that could solve problem

Shared Mental Models : 

Shared Mental Models Exploiting entire team’s cognitive capabilities Assure all team members are solving same problem

Shared Mental Models : 

Shared Mental Models Strategies Explicit discussion of problem Closed loop communication Volunteering necessary information Requesting clarification Providing reinforcement, feedback, confirmation

Resource Management : 

Resource Management Assuring time, information, mental resources will be available when needed Prioritize tasks Allocate duties/delegate Keep team leader free Keep long enough time horizon to anticipate changes in workload

Practical Crisis Management : 

Practical Crisis Management

Take Command : 

Take Command Be sure everyone knows who is in charge Decide what needs to be done Prioritize necessary tasks Assign tasks to specific individuals Control should be accomplished with full team participation Leader should be clearinghouse for information, suggestions

Take Command : 

Take Command

Take Command : 

Take Command “Authority with Participation” “Assertiveness with Respect”

Declare Emergencies Early : 

Declare Emergencies Early Risks of NOT responding quickly usually far exceed risks of not doing so.

Emergency Event Time-Severity Relationship Curve : 

Emergency Event Time-Severity Relationship Curve

Good Communication = Good Teams : 

Good Communication = Good Teams Do NOT raise your voice If necessary ask for silence State requests clearly, precisely Avoid making statements into thin air Close the communication loop Listen to what people say regardless of job description or status

Communicating Intent : 

Communicating Intent Here’s what I think we face Here’s what I think we should do Here’s why Here’s what we should keep our eye on Now, TALK TO ME

Good Communication = Good Teams : 

Good Communication = Good Teams Concentrate on what is right for the patient rather than on who is right

Distribute Workload : 

Distribute Workload Assign tasks according to people’s skills Remain free to watch situation, direct team Look for overloads, performance failures

Optimize Actions : 

Optimize Actions Escalate RAPIDLY to therapies with highest probability of success Never assume next action will solve problem Think of what you will do next if your actions do not succeed or cannot be implemented Think of consequences before acting

Reassess--Reevaluate--Repeatedly : 

Reassess--Reevaluate--Repeatedly Any single data source may be wrong Cross-check redundant data streams Use ALL available data

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