Anesthesia Crisis Resource Management (ACRM)

Development of the ACRM Concept

			Crisis management skills are exercised during ACRM training

Based on experiments performed by the Laboratory for Human Performance in Health Care (LHPHC) -- see annotated bibliography for listing of earlier studies on clinical decision-making) and by others in the 1980s, LHPHC faculty began to develop a model of the cognition (thinking processes) of anesthetists. From this model, they began to realize that the performance of both novice and experienced anesthesiologists was limited in certain ways. For example, certain abnormal situations were not recognized quickly, or else the response to them on discovery was haphazard and slow. Also, even when the anesthetist knew what needed to be done, they could not always work effectively with other personnel (surgeon and nurses) to get things done in time. The LHPHC analysis of anesthesia training revealed several gaps. It was assumed that during training anesthesia residents would learn "by osmosis" to recognize abnormal situations and to deal with them. There was no systematic training in handling critical events, and no reference source for such information. Every other work environment in which critical events must be handled appropriately and quickly relies on manuals of emergency procedures to prepare personnel in advance and to support them as they manage crisis situations. Three LHPHC faculty wrote a Catalog of Critical Events in Anesthesiology which is the manual of emergency procedures for anesthesia. Using this catalog as a reference resource it was hoped that anesthesiologists could prepare in advance to recognize events and to treat them with logical, efficient plans.

The second, even bigger, gap in training was that no one was taught how to act in managing a critical event or crisis. Sound medical and technical knowledge is not enough. Anesthesiologist need to know how to manage a variety of resources effectively, bringing them together in concert as necessary to deal with the situation. These behaviors have been studied very carefully in aviation and special training courses in "Cockpit [now Crew] Resource Management" (CRM) have became standard for major air carrier pilots. The LHPHC team adapted many CRM concepts to anesthesiology, developing an approach termed "Anesthesia Crisis Resource Management" (ACRM).

There are several key behaviors principles in ACRM

			Team work and effective communication are exercised during ACRM

• Anticipation and Planning
• Communication Leadership and Assertiveness
• Use of all available resources
• Anesthesia resident utilizing a cognitive aid during ACRM training
• Distribution of Workload & mobilization of help
• Re-evaluation of situations
• Use of all available information and cross checking of redundant data

Such behaviors are NOT taught in anesthesia training programs, although good practitioners have learned these behaviors from experience. However, every practitioner can improve at them, and many residents and practitioners are not skilled in these matters. The ACRM training program focuses on these types of generic crisis management behaviors, emphasizing teamwork and coordination of resources in a realistic and full-scale simulation environment.

• Real anesthesia cart and real drugs are used during training
• Trainees perform all anesthesia tasks, including charting during their ACRM training
• "Crisis Management in Anesthesiology", a textbook incorporating didactic materials on crisis management behaviors as well as the Catalog of Critical Incidents in Anesthesiology (83 events). (Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesiology. New York, Churchill Livingston, 1994)

			Three anesthesia residents distribute the workload during management of a patient crisis situation