Stanford School of Medicine
VA PA Sim Center–

Crisis Resource Management Training in Emergency Medicine


ED residents and EMCRM faculty after completing advanced-level EMCRM training. Course Faculty: Kanthi Kiran, MD (first row; third from the right); Phillip Harter, MD (first row far left); Chantal Lisette Rawn (second row far right).

Rebecca Smith-Coggins, MD+ Phillip Harter, MD+ Martin Reznek, MD+
Kanthi Kiran, MD+ Chantal Lisette Rawn# Thomas Krummel, MD#
Steve Howard, MD* Yasser Sowb, PhD* David Gaba, MD*

+Division of Emergency Medicine
#Department of Surgery
*Simulation Center for Crisis Management Training in Health Care
VA Palo Alto Health Care System
Stanford University School of Medicine

Description of EMCRM

High-fidelity Patient Simulator

Issues related to scenario design, scenario debriefing and course organization

Emergency departments are complex and dynamic working environments in which crises can be common occurrences. Emergency physicians must be equipped to recognize and avert impending crises and resolve active ones. While crisis management is clearly an integral part of the practice of emergency medicine, emergency medicine residents historically have received little to no formal training in this area.

Environments with similar dynamics and complexity exist in other professions. In the aviation industry, the need for crisis management training of its professionals has been recognized for many years. Studies of decision-making and human error during actual airline disasters revealed that certain skills necessary for optimal navigation through complex and rapidly evolving situations were not being taught in their traditional training. In response, a flight curriculum called Crew Resource Management (CRM) was developed to teach pilots these necessary teamwork and leadership skills. CRM has been so successful that it is now required on a recurrent basis for all U.S. flight crews before they are permitted to fly.

In the late 1980’s, recognizing that the working environment in aviation was similar to that in anesthesia, anesthesiologists at the VA Palo Alto Health Care System and Stanford University developed Anesthesia Crisis Resource Management (ACRM). In addition to incorporating the principles of CRM to the practice of anesthesia, they also designed a high-fidelity patient simulator and operating room environment in which to teach the course. ACRM has been extremely well received. A textbook on ACRM has been published in several languages and ACRM is now a standard course for several US residency programs and multiple simulation centers around the world.

The principles of CRM and ACRM apply to any profession that is highly complex, dynamic and prone to crisis. Like anesthesia and aviation, we feel that emergency medicine training would be significantly improved by the addition of a structured crisis management curriculum. In response, a collaborative effort of the Division of Emergency Medicine, the Center for Advanced Technology in Surgery at Stanford, and the original creators of ACRM has resulted in the creation of Emergency Medicine Crisis Management (EMCRM). This course will become an essential component of the training of emergency medicine residents at Stanford University.

Description of EMCRM


Background

The creation of EMCRM was proposed following careful study of the ACRM curriculum. The seven management behaviors emphasized in ACRM also apply directly to the practice of emergency medicine (Table 1). Given this overlap, we felt that ACRM represented a strong foundation on which to build EMCRM. While the seven ACRM behaviors are necessary for optimal crisis management in emergency medicine, they are not sufficient because the practice of emergency medicine presents unique challenges that are not often experienced in anesthesiology. For this reason, three additional key crisis management behaviors were added to EMCRM (Table 1). With this in mind, scenarios specific to emergency medicine were designed for EMCRM, but the general structure was adapted directly from ACRM.

Table 1- Key Crisis Management Behaviors of EMCRM

Key Crisis Management Behaviors shared by EMCRM and ACRM

1. Anticipation / Planning

2. Communication

3. Leadership / Assertiveness

4. Awareness and utilization of all available resources

5. Distribution of workload and mobilization of help

6. Routine re-evaluation of situation

7. Awareness and utilization of all available information

Key Crisis Management Behaviors added for EMCRM

8. Triage / prioritization

9. Efficient management of multiple patients

10. Effective coping with disruptions/distractions

Setting

The Palo Alto VA/Stanford University Simulation Center. In addition to several offices, the functional portion of the center consists of four rooms: the simulation room, a clinical workroom/supply room, a control room and a conference room for debriefing (Figure 1). The simulation room houses the mannequin simulator and can be formatted to look like an operating room, an ICU, a delivery room or an emergency department patient care area. For EMCRM, we included the following: a cardiac monitor, a ventilator, an infant warmer, a crash cart, three ED supply carts, an area for patient-actors and a sign-out board. The simulation room has three video cameras and is separated from the control room by a one way glass.

 

High-fidelity Patient Simulator


The Palo Alto VA/Stanford simulation center has used the MedSim-Eagle patient simulator version 2.4 (MedSim Inc., Ft. Lauderdale, FL) in the past. Currently, the Human Patient SimulatorÔ (Medical Education Technologies, Inc., Sarasota, FL), and SimManÔ (Laerdal, TX) are also being used.

The patient simulator consists of a high-fidelity mannequin and a desk-top computer that are interconnected. The life size, full-body mannequin has several electronic and mechanical devices that allow it to realistically simulate the physical properties of a live patient. The mannequin can open and close its eyes, move its upper extremities, and speak (via a speaker in the mannequin's pillow controlled from a microphone in the control room). In addition, the mannequin “breathes” spontaneously (or can be mechanically ventilated) with two servo controlled lungs (linked to an in-board gas analyzer) that are capable of exhaling a gas mixture that has the appropriate increase in CO2. The mannequin also has several anatomically correct clinical signs including: breath sounds associated with the chest rise, heart sounds, palpable carotid and radial pulses, peripheral blood pressure, muscle twitch from peripheral nerve stimulation, and pupilary reflexes. The mannequin is designed to interface with several conventional monitoring devices allowing for real-time recording of the electrocardiogram, respired carbon dioxide levels, pulse oximetry signal, invasive pressures (arterial, CVP and PA), cardiac output and temperature.

The simulator computer models the "patient's physiology” and drives the appropriate physical responses in the mannequin. In addition to simulating the baseline physiology, the computer also models realistic physiologic reactions to injuries (e.g. a dilated pupil from head trauma) and medical interventions (e.g. placement of a chest tube for pneumothorax). The computer has appropriate phamacokinetic and pharmacodynamic models for approximately 70 medications. Several physical interventions are possible, including intubation (endobronchial or esophageal intubation are possible given the simulator's anatomically correct airway and esophagus), chest compression, positive pressure ventilation, electrocardioversion, cricothyroidotomy (laryngospasm can be simulated and the upper airway can be made to swell to simulate edema, making intubation difficult or impossible), peripheral catheter insertion and central venous catheterization.

Participants
The following is a list of the number of participants, instructors, and actors necessary to run an EMCRM course:

· Resident participants – 3 to 5 (Participant numbers smaller than three lead to confined discussion during debriefings, while a course for greater than five makes the course prohibitively long.)

· Nurse participants – 1 to 2 (recommended)

· Medical student participants - 1 to 2 (optional)

· Instructors – 2 or 3 (each scenario requires a captain/supervisor to directs the scenario, an operator to run the simulator and a facilitator to observe the scenario, record the pertinent events and then direct the debriefing – these roles can be rotated from scenario to scenario) Instructors can be attendings, fellows, senior residents or private practitioners that have had special training in conducting and teaching this curriculum.

· Confederate nurse – minimum of 1

· Scenario actors – minimum of 3 (extra instructors can function as actors when not supervising or debriefing)

Course outline

The EMCRM course is designed to run for approximately 6-8 hours (depending on the number of participants and scenarios). Prior to the day of the course – The participants are given the first two chapters of the ACRM textbook to review. These chapters outline general theories of human and systems error and introduce the key principles of crisis management.

Informal period/Breakfast – The day begins with an informal introductory period intended to relax the participants. Some participants experience initial apprehension because of their perception that their skills are being tested during EMCRM. We have found that informal socializing over breakfast and coffee is an effective start to the day as it eases some of this tension. If research is taking place, consent forms are explained and signed at this time.

Introduction – Following this informal period, a presentation is given by one of the instructors outlining the background and goals of EMCRM as well as a brief description of the day’s events. Participants are assured that the purpose of the course is not to evaluate individual performances but rather to focus on learning the key crisis management behaviors. The instructor emphasizes that the debriefing sessions are more effective when the participants actively engage in self-learning and the ideal role of the instructor is to only facilitate the participants' discussion. It is also important for the instructor to warn the participants that the scenarios are designed to be stressful in order to maximize the learning experience.

The instructor finishes with a discussion of confidentiality. Both the individual performances and the nature of the scenarios are to be kept confidential. The instructor emphasizes that the participant performances are to "stay within the walls" of the simulation center. In addition, the participants are not graded and their performance does not become part of a permanent file. It is also emphasized that realistic and educationally valuable scenarios are difficult to design and therefore they are limited in number. They are used repeatedly and will lose educational value if future participants learn of them before taking the course. All participants, instructors, actors and observers must sign a confidentiality agreement before participating

Airline crash documentary – A ten-minute segment of the NOVA documentary, "Why Planes Crash" is shown (the Public Broadcasting System, Alexandria, VA). Included in this segment is a flight-simulator reenactment based on the cockpit voice recording of an actual commercial airplane crash that killed 99 people. The recording reveals that this devastating accident occurred because of simple and easily avoidable human errors by the pilots and air traffic controller. Seeing three highly skilled pilots fly an L-1011 into the Florida Everglades is very effective at enhancing the participants’ buy-in to the importance of EMCRM. The participants are urged to discuss the similarities of medical disasters that they have encountered to the situation portrayed in the video.

Didactic session – A brief lecture is given highlighting the key crisis management behaviors of EMCRM.

Familiarization with simulation room and mannequin – Approximately 30 minutes is dedicated to familiarizing the participants with the mannequin and the simulated ED. In this session, participants are told the "ground rules" for working in the simulator environment. It is important to strongly emphasize that for the scenarios and the course to be maximally effective, the participants must make an effort to suspend their disbelief. Although the simulator is very realistic, it does have several shortcomings that are obvious. For example, the skin is plastic and cannot change color, vary its temperature or produce sweat. If a participant desires this type of information, they must perform the appropriate actions to obtain it, and an answer will be given over the simulator room loudspeaker.

Real trauma video – A fifteen-minute video of an actual trauma resuscitation is shown to the participants. This is followed by a half-hour discussion of the EMCRM principles relating to the video. This portion of EMCRM is important for two reasons; it provides an opportunity for the participants to practice discussing the EMCRM key behaviors, and it promotes team building among the participants.

Scenarios and debriefing - For each scenario, one resident participant is considered to be in the “hot seat”, as they are the primary physician responsible for the care of the "patients". The remaining resident participants observe the scenario from the conference room by video link. One of these observers is designated to be the “first-responder”. The “hot seat” participant can page the first-responder for assistance at any time during the scenario. A minimum of two nurses is necessary for the scenarios to run smoothly, one of whom must be a confederate nurse. The confederate nurse wears a headset to allow direct communication with the supervisor in the control room. This can be very useful, for example, if the participants are persistently overlooking an important detail during the scenario. The supervisor can instruct the confederate nurse to prompt the participants to discover the missing detail. Unlike the confederate, the nurse participant(s) have no prior knowledge of the scenario, and they are instructed to participate as they would in a real ED. Medical student participants are not necessary, but they can be helpful both as another resource for the "hot-seat" resident as well as another point of view during the discussions.

Several roles require actors. Each scenario begins with either a paramedic or resident sign-out. The debriefing facilitator can play this role if necessary, but an actor is better so the facilitator can preside over the recording computer for the entire scenario. Actors are required for the roles of other standardized patients as well as consulting physicians. In addition, a respiratory therapist is commonly requested by the "hot seat" participant during the scenarios and should also be played by an actor or one of the participants not actively involved in that particular scenario.


Resident and ED nurse manage a patient during an EMCRM scenario (confederate nurse with headset on right).

Two ED residents communicate their management of multiple patients during EMCRM.

ED residents perform an emergency cricothyroidotomy on the simulated patient.

ED resident defibrillating a cardiac patient.

Once enough material has been amassed for a constructive discussion of the EMCRM principles, the scenario can be stopped. It is important to note that not all of the principles need to be covered in a single scenario, and it is not necessary for the participants to "finish" the scenario for the debriefing to be effective. (The founders of ACRM have noted that, unless required for a specific teaching goal, allowing the simulator to "die" can be detrimental to the attitude of the “hot seat” participant and can interfere significantly with the debriefing session.) Generally, the scenarios run between 20 to 30 minutes and the debriefing sessions last between 30 and 45 minutes. During the course of the day, each participant should be in the “hot seat” and first-responder positions at least once.


A debriefing session during which residents' performance during the simulation scenario is discussed. Dr Becky Smith-Coggins, EMCRM Instructor (close to TV monitor).

A debriefing session by Dr Phillip Harter, EMCRM Instructor (right).

 

Conclusion – A brief wrap-up session includes a reminder of the importance of confidentiality and a request for the participants to sign a consent form for the release of videos and still photos for research and educational purposes. In addition, the participants are given the opportunity to ask questions and give verbal feedback, and time is allocated for the participants to complete a written evaluation of the course.

Issues related to scenario design, scenario debriefing and course organization


Scenario design - It is challenging to design realistic scenarios that will consistently elicit meaningful EMCRM discussions. In general, we have chosen to simulate illnesses or injuries that are challenging due to their urgency, severity or rarity. We have found that it is better to avoid disease complexity because it is harder to make fully realistic, can often challenge the limitations of the simulator, and is much more difficult for the supervisor to manage.

The patient actor roles are designed to mimic the multiple patient nature of the ED and to serve as distractions in the scenarios. It can be difficult to prevent the participants from being hyper-vigilant with regard to the mannequin and neglecting the actors. This is only a minor problem because the participants still interact with the standardized patients in some capacity, and usually there is ample material for discussion. Careful planning of the acted roles can help to minimize the hyper-vigilance. It is important to have patients whose medical or social issues dictate that the participant should not or cannot dismiss them from the room. We have found that suicidal or extremely demanding patients are effective in this capacity. To further decrease participant hyper-vigilance, we are also planning to design some scenarios that focus more on the patient actors rather than the mannequin. Another possible solution to this issue is having multiple mannequins in the scenarios. This has been attempted at another institution with some success. However, at this early stage in simulation training for medical education, it is extremely rare for an institution to have access to more than one simulator.

Other types of distractions during the scenarios can also be realistic and effective. In order to illicit other important ED management issues during the scenarios, we have added outside ambulance and mass casualty triage calls, disruptive non-ED physicians and challenging patient family members.

Scenario debriefing - A skilled facilitator is essential for effective EMCRM debriefing sessions. A thorough discussion of proper debriefing techniques is beyond the scope of this article. Scientists at the NASA Ames Research Center have produced a training manual for flight simulator debriefing that the founders of ACRM have recommended to their ACRM instructor trainees for many years (McDonnell LK, Jobe KK, Dismukes RK. Facilitating LOS debriefings: A training manual. Moffet Field (CA): NASA-Ames Research Center; March 1997. NASA Technical Memorandum 112192). In general, the facilitator in EMCRM is present only to guide the discussion among the participants and to assure that they address the important issues from the scenario. Self-learning is believed to be more effective for adults than simple didactic education. For this reason, questions directed to the facilitator generally are reflected back to the group for further discussion. However when the group is unable to settle an issue and the expertise of the facilitator may be required. The goal of the debriefing sessions is to spend approximately 60% of the time on discussion of EMCRM behaviors and 40% on medical management issues.

Course organization - A successfully run EMCRM course requires meticulous organization because multiple tasks must be performed simultaneously throughout the course. Efficiency is also important because of the significant faculty investment and man-hours that are required. A preset time-line of the day's events should be strictly followed to ensure that the course is completed in a timely fashion. In addition, the roles of the instructors and actors for each scenario should be determined well before the course begins and posted in the control room in order to ensure that the course runs smoothly.

Conclusion
Although, the objective evaluation of EMCRM will not be completed for several years, it is our opinion that crisis management training for residents is very important. Based on the success of EMCRM’s predecessors, CRM and ACRM, coupled with overwhelming positive response from participants in pilot courses, we have adopted EMCRM as a permanent portion of the emergency medicine resident training at Stanford University. In addition, we strongly encourage other institutions to join us further evaluation and development of simulator-based training.

"No industry in which human lives depend on skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it.” – David M. Gaba, M.D.

Article on EMCRM (in PDF) published in Academic Emergency Medicine- pdf link not found

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