How to enhance your success in your teamwork using the 15 CRM Key Points by Rall and Gaba, whilst reducing your risk of mistakes professionally, you can read here:
What are the 15 Key Points by Rall and Gaba?
To start with, we will elucidate the origin and the purpose of the Key Points, before we take a closer look at the first five of them in this first part of the new blog article series.
Why Do Mistakes Happen in Medicine?
Often, it is not due to a lack of knowledge, manual skills, or a lack of volition to work professionally. Rather, it proves to be difficult to apply the skills in a real situation as a team confidently, whilst realising errors so early that they do not harm our patients.
The two anaesthesiologists and pioneers in patient simulation, Dr David M. Gaba and Dr Marcus Rall clearly realised this and have since then been working hard to adapt crew resource management, which is well established in aviation, to the field of medicine and to integrate it into the workflow in prehospital emergency medicine and in the hospital.
The Formulation of the Key Points
One centrepiece of their work are their 15 CRM Key Points (1). In these, they have briefly and concisely summarised how to organise teamwork using CRM and good communication in a manner which allows us to help our patients safely and efficiently. The Key Points are a guide on how to apply all skills as a team in complex circumstances, to master critical situations, and to minimise mistakes.
1 Rall M, Gaba DM: Human performance and patient safety. In Miller’s Anesthesia. Edited by Miller RD. Philadelphia, PA: Elsevier, Churchhill Livingstone, 2009:93-150
1. Know the Environment
Safety in Critical Situations
If you have been at your workplace for a long time already, you know it inside out, perhaps without thinking long about the safety which the well-rehearsed workflow offers you.
Now, imagine that you are really busy when you, all of a sudden, and on top, are asked to copy three different documents for the head of your department. "Of course", you may think, but, as you reach the room in which the copier is, you discover that there is a new and complex device, which you have never seen before, let alone that someone has familiarised you with it....
At the office, you can still find a way out, there is always time pressure, but no-one will asphyxiate until you have solved the problem. At other workplaces, such as the cockpit of an airliner during an incident, or during an operation when the patient's blood pressure suddenly drops dramatically, one wouldn't like to imagine what it would be like if one was confronted with new equipment, or medication without any preparation.
Therefore, in aviation, but also in the prehospital emergency medical service, one makes sure very carefully that every teammember knows the work environment. What belongs to it in the emergency medical service? Please pause for a moment and imagine it the best you can.
The Working Environment in the Emergency Medical Service
First of all, you may have thought of ambulances and doctor's cars with all their equipment and consumable supplies. To be up to date here is irremissible as, for instance, the ECG device, which during resuscitation, or when treating cardiac dysrhythmias, has to be operated swiftly, may receive new software, or be replaced by a new model.
In addition, it is important to know the area well. We need to know where the rescue stations are, and from where a doctor's car could come after what time, where the helicopters are based, and which hospitals in the region offer what departments. We need to choose the right hospital early when we, for example, treat a patient with a stroke, a heart attack, or a severe trauma.
Furthermore, every area has its own specialties, for instance, chemical factories, forestry with wood processing, or sections of a motorway, due to which we need to expect certain patterns of injuries.
2. Anticipate and Plan
In this Key Point, there are two items. First, the mental anticipation of what could happen next. Therefore, for instance, good pilots are always ten miles ahead of their planes in their minds. Second, there is planning, the preparation for what one has anticipated.
With these two steps we achieve that we are already attuned to the eventualities instead of having to start thinking about possible solutions only in the actual situation. Hence, we can reduce the stress, act more safely and with a better overview, and avoid dangers. In addition, we can make time-critical decisions earlier.
En Route to a Scene
After having been alerted with a certain keyword and on our way to the scene, we try to prepare for the call as early as possible. This entails to gather all the information from the dispatcher, as well as from the first vehicles on the scene.
For instance, we ponder on how many patients we will have to treat, what their illnesses, or injuries might be, and what hospitals we might have to choose. Furthermore, we evaluate whether we should transport our patients in an ambulance, or whether it would be better to call a helicopter to the scene.
In addition, we take circumstances such as the weather into our account. A patient after a cycle accident can lie in the searing heat, or in iciness. There can be dangers at the scene, such as leaked petrol, or vehicles which may be lying on a slope, from where they can slide down or tumble once more. In our minds, we prepare to rescue people from such situations.
The Weather During a Flight
Pilots receive continuously updated information on the weather on their route before and during their flight. When they fly through the Tropics, there can be severe thunderstorms, and the pilots have to consider whether they want to fly around these zones.
Moreover, they have to deal with severe weather conditions at their destination as they may have to plan for a landing at another airport in order not to jeopardise the souls on board.
Which airport would be suitable in the first place? Is there enough fuel to reach it? As airlines think very economically, also the following considerations have to be taken into account. How will passengers with connecting flights continue their journey? Will there be the need to stay overnight if it is late already? Will the pilots' maximum time of duty be exceeded? The latter was also a major concern of the KLM crew before the accident on Tenerife in 1977 (page 41).
3. Call for Help Early
This is not about being too weak for a task, or being incompetent, but about anticipating early that one will carry out the actual task more safely and efficiently with additional help. Furthermore, one shows that one is aware of one's responsibility, but also one's resources.
The following examples will show you how varied help is.
A Rescue Team Needs Help
We meet some patients, who are immobilised due to an injury, in labyrinthine buildings on an upper floor. In some cases, the patient is not really slim in addition. Then, we think early about the help we will be needing to carry him or her downstairs to the ambulance safely. According to the circumstances, we either call another team to help us to carry the patient through the staircase, or the local fire department in order to rescue the patient through the window using the aerial ladder.
In prehospital trauma life support, PHTLS, a team considers as one of the first things, what emergency services are on the scene already and what other services it might still be needing. So, after some accidents, fire engines are required (for instance, to stabilise a car on a slope). After other accidents, specialists to rescue people from the water, heights, or from the depth have to be called.
We Ask the Consultant
A residency takes a long time, and young doctors need help according to their current knowledge when on duty. Here in particular the awareness of responsibility is demonstrated if a young colleague assesses her knowledge and skills appropriately and realises that she rather discuss the complex fracture of patient's forearm with her consultant.
In doing so, she can definitely show that she is not incompetent if she, along with all relevant information about the patient, presents all her considerations concerning possible complications and types of treatment according to her current knowledge.
How to Avoid Unnecessary Delays Skilfully
If we consider further help early and call for it, logically it will reach us earlier, as well. That, in turn, helps us to free a patient earlier from an awkward situation, or treat a painful condition, such as the fracture of a forearm, more rapidly. In addition, we have more time to find an alternative if the help, we had considered in the first place, should not be available.
4. Excercise Leadership and Followership with Assertiveness
In many professions and businesses, the roles are clearly defined, and everone knows who the leader is. Regardless whether his or her position is fixed, or whether a team of three on an ambulance decides who will lead during the next call, we need someone who leads.
The tasks of a teamleader are varied, and it is important with respect to the successful completion of a call that the teamleader performs these tasks. This does not mean that the teammembers should stop thinking. Rather, their competent action is vital. It is well-known that a chain is only as strong as its weakest link.
A Teamleader's Tasks
A teamleader coordinates a call by distributing the tasks, monitoring their execution, and giving a teammember a new job to carry out after completion. He or she pulls all the strings and gathers all information.
The teammembers support him or her actively by reporting when tasks are finished, but also if they have received too few, too many, or too difficult a task. Through this, the teamleader can distribute the jobs appropriately to the entire team.
The teamleader gathers also the information from the teammembers and makes certain that the whole team knows the relevant part of it. Moreover, he or she sees to it that a common mental model is established, for example, that everyone knows the working diagnosis.
The Teammembers Contribute Actively and Make Their Voices Heard
The teammembers take on the tasks and use all of their skills to complete them. They support their teamleader actively with their confirmations.
In today's teams it is especially important that everyone regardless the position within the team should voice ideas, or point out potential errors if necessary by speaking up, which you know well by now.
Also, everyone may call for a team timeout at any time so that the team can reevaluate in a structured manner and plan the next tasks. We will deal with this in more detail when we shed light on the 10-for-10 concept below.
Taken together, you see that at any position in the team knowledge, skills, and attitude are required. The team joins all of these together in order to care for their patient safely.
5. Distribute the Workload (10-for-10 Concept)
Using the distribution of the tasks as discussed above, one assures that the workload is distributed wisely and that all teammembers contribute adequately.
How to Complete All Tasks Without Redundancy
When we come to a patient and his or her relatives as a rescue team, many tasks are to be completed almost simultaneously. In a structured manner, the teamleader starts the anamnesis, whilst the teammembers begin to take the vital signs and to prepare an ECG according to the patient's condition.
The relatives want to be heard, as well, and they often provide us with important information, such as medication regimens, or physician's letters, which we need to consider.
Following that, the treatment and further proceedings are defined in accordance with the diagnosis.
The distribution of the workload helps to finish all tasks without any omissions efficiently. Using wise coordination and feedback, the teamleader ascertains that no tasks are carried out in redundancy.
For example, a task done twice might be if two teammembers ask the patient and his or her relatives the same questions about the patient's past medical history.
The 10-for-10 Concept
If the situation becomes complex and confusing due to the sudden deterioration of the patient's condition, it has stood the test of the practice to apply a so-called team timeout. In this, 10-for-10 stands for "ten seconds for the next ten minutes."
The entire team (except chest compression during resuscitation) summons its attention and discusses in a structured manner what the situation is, and what measures have to be taken in what order, and by whom. The tasks are distibuted accordingly. One actively discusses whether there are any further questions, or issues. As soon as this is negated, the team proceeds as agreed.
Even if it seems to be against the intuition at first to interrupt work in a complex situation, one recovers the lost time, because of the efficiency due to the deft coordination of the tasks. In addition, the team has achieved an overview, and, thus, reduction of the stress, which, in turn, diminishes the risk of errors.
6. In the Next Blog Article, We Will Continue Our Work
Already when looking at our first five Key Points you could see that they are intertwined with one another. In the course of the next two blog articles, we will discover more of these interdependences. Furthermore, we will elucidate to which category of CRM, for instance, communication, each Key Principle belongs.
In October, we will work on five more Key Points. Amongst others, we will occupy ourselves with how to use resources and information, and how to communicate without misunderstandings. We will unveal what fixation errors are, and how to avoid them.
Author: Eva-Maria Schottdorf
Date: September 23rd 2022
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