EM · Team-based care and CRM
Team-based care and crisis resource management in the emergency department
Also known as Crisis resource management · Non-technical skills · Teamwork in the emergency department · Closed-loop communication · SBAR and ISBAR handover · Situational awareness · Fixation error · Authority gradient · Psychological safety · Team debrief
Team-based care and crisis resource management (CRM) in the emergency department — the non-technical skills (leadership, communication, situational awareness, decision-making, resource management) translated from aviation to medicine; the allocated team roles and the team leader who stands back; closed-loop communication and the structured ISBAR/SBAR handover; the three levels of situation awareness and the three fixation errors; authority gradient and psychological safety (CUS, two-challenge rule, leader inclusiveness); the hot debrief and plus-delta; simulation and in-situ latent-threat identification; error prevention through checklists and cognitive aids (WHO surgical checklist, Pronovost central-line bundle); and the differential of team failures — solo-practice collapse, communication breakdown, authority-gradient suppression, fixation error. ACEM-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- A team leader who performs procedures loses situational awareness and the oversight of the resuscitation — the leader stands back and directs
- Fixation error (the failure to revise a working diagnosis in the face of contradictory evidence) is a leading cause of failed resuscitation — the defence is structured reassessment and explicit naming of alternatives
- An uncorrected closed-loop communication failure allows an instruction to be assumed but never executed — the loop closes only on confirmation
- The steep authority gradient suppresses the subordinate who sees the error — a flat, psychologically safe culture and explicit invitation of dissent are the countermeasure
- The event without a debrief is the event whose lessons are lost — the hot debrief plus-delta is run with the team present immediately after
Meet the patient
The arrest call sounds at 03:00 for a 64-year-old collapsed in the waiting room. By the time you reach the bay, two nurses, a registrar, an intern and a technician are crowding a patient in ventricular fibrillation — and nobody has been told who is doing what. The defibrillator is on, but no one is owning it.[11]
The next sixty seconds decide whether this is a team event or five people reaching for the same airway. The two questions that govern the whole resuscitation are the two that govern every CRM exam stem: who is in charge, and does that person still see the whole picture? Hold those two and every principle below slots into place.[3]
References14ShowHide
- [1]Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systematic review of the past decade Hum Resour Health, 2020.PMID 31915007
- [2]Buljac-Samardžić M, Dekker-van Doorn CM, Maynard MT What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness J Patient Saf, 2021.PMID 34852415
- [3]Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature Acta Anaesthesiol Scand, 2009.PMID 19032571
- [4]Salas E, DiazGranados D, Klein C, et al. Does team training improve team performance? A meta-analysis Hum Factors, 2008.PMID 19292013
- [5]Tannenbaum SI, Cerasoli CP. Do team and individual debriefs enhance performance? A meta-analysis Hum Factors, 2013.PMID 23516804
- [6]Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians Jt Comm J Qual Patient Saf, 2006.PMID 16617948
- [7]Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med, 2009.PMID 19144931
- [8]Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU N Engl J Med, 2006.PMID 17192537
- [9]Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes Am J Surg, 2009.PMID 18789425
- [10]Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias Acad Emerg Med, 2002.PMID 12414468
- [11]Greif R, Bhanji F, Bigham BL, et al. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Resuscitation, 2020.PMID 33098918
- [12]Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program N Engl J Med, 2014.PMID 25372088
- [13]Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC. I-pass, a mnemonic to standardize verbal handoffs Pediatrics, 2012.PMID 22232313
- [14]Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department BMJ Qual Saf, 2013.PMID 23258390