1. Pediatrics
Crisis Resource
Management
Kevin Roy
Critical Care Medicine

2. Page 1
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
What is CRM
• Encompasses skills crucial to functional teams
• Non-Technical Behavioral skills
‐ Team Roles/Leadership
‐ Communication
‐ Resource Utilization
‐ Situational Awareness/Mental Modeling
• Historical Significance
• Practical Applications of CRM principles
‐ Scenarios
‐ Clinical Duties

3. Page 2
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Before we Start:
• Introductions
• Goals For Discussion
1. Review Importance OF CRM Skills
2. Understand Components of CRM
3. Discuss how Each Component is Applicable to
Scenarios/Experiences
4. Discuss how CRM Skills are Applicable to Work Environment
5. Safe Environment to Learn from the Group’s Pooled
Experiences

4. Page 3
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Historical Importance of CRM
•67% of Aviation crashes were from communication, leadership and
other team training deficiencies
•70% of mistakes in medicine due to human error
•Communication is deficient in 70% of perinatal sentinel events (Joint
Commission)
•Mock code training improved survival after cardiac arrest from 33% to
50% (Andreatta P et al, 2011 Pediatr Crit Care Med)
•Hasbro Children's hospital showed decreased medical error rates with
simulation-based team training from 30.9% to 4.4% (CHCA, 2008)

5. Page 4
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
CRM throughout TCH
•TCH Sentinel Events: Nearly all had a recognizable
deficiency in CRM Skills
‐63% Lack of Information Sharing
‐45% Lack of Clear Hierarchy
‐45% Poor Teamwork Coordination
‐34% Poor Communication Style
‐21% Lack of Clarity Team Roles
‐Only 13% Fatigue, 16% Thought Process
•Relationship with Latent Safety Threats

6. Page 5
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
CRM at TCH: PICU Code Debriefings
•Only 2 events(6%) were perceived as error-free
• Systems issues were identified by at least 1 team
member in 60% of events
•BLS/PALS deficiencies in 60% of events
•CRM deficiencies in 83% of events

7. Page 6
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
CRM Deficiencies in PICU Codes
•Communication Deficiencies 45 %
•Closed Loop Communication
•Team Roles Deficiencies 54%
‐ 46% Lack of clarity about team leadership
•Situational Awareness 32%
‐ Available information not utilized and Planning for Crisis
•Utilization of Resources 18%
‐ Appropriate Help not called early

8. Page 7
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Reviewing CRM Principles
•Origin of these CRM principles
•Categories and subcategories:
‐Communication
‐Role Clarity
‐Resource utilization
‐Situational Awareness
•Relationship with Latent Safety Threats

9. Page 8
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
The importance of CRM

10. Page 9
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Communication
•… Some people are just good at it
•… You know it when you see it
•Communication is made up of Specific Crucial Components
‐ Closed Loop Communication
‐ Specific to person, place, and thing
‐ Assertive (but Calm)
• “Non threatening way of garnering attention”
• Avoid Unnecessary Vagueness
‐ Standardized Critical Language
• “Code, Pulseless, CPR, Pulmonary HTN Crisis”
• SBAR, TEAM STEPS, CUS (Concerned, Unsafe, Scared)
•Examples

11. Page 10
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Category 1: Communication

12. Page 11
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics

13. Page 12
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Recap: Communication
• Calm and “professional” environment
• Closed loop communication
• Clear communication of critical events
• Team leader communicates plan to group
• Team members are empowered

14. Page 13
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Team Roles
•Depend on the Situation
•Code/Potential Code:
‐ Team Leader
‐ Airway
‐ Cardiovascular
‐ Bed Side RN
‐ Code Cart
‐ Other: Runner, Crowd Control/Parental Support, Documenter
•One Role : One Person
‐ Trust Other Roles
‐ Team Leader’s Responsibility to assign?
‐ Switching possible If needed or new personnel arrive
•Other Situations or Examples?

15. Page 14
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Leadership
•Leadership: Definition?
•Command the team
‐Identify Early
‐Final Decision Maker (not omniscient decision maker)
‐Maintain Calmness
‐Stand Back
‐Key component to other CRM skills
•Lessoning the impact of hierarchy
‐“Leader” doesn’t necessitate “Followers”
‐Allowing good ideas
‐Bringing out good ideas

16. Page 15
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Category 2: Role Clarity

17. Page 16
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Recap: Role Clarity
• Team Leader Identified
• Team roles identified
• Team members focus on their roles
• Effective handoff of roles

18. Page 17
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Utilization of Resources
•Right People, Right Equipment, at the Right Time
•Maximizing potential of those resources
‐Right role for each person
‐Using Equipment correctly
•Getting the resources you will need 5 minutes from
now
•Examples

19. Page 18
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Category 3: Utilization of Resources

20. Page 19
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Category 3: Utilization of Resources

21. Page 20
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Recap: Utilization of Resources
• Call for help early
• Workload distributed optimally
• Appropriate Assignments
• Appropriate equipment

22. Page 21
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Situation Awareness
•Decisions are based on percieved situation
•Rapid assessment
‐Allows appropriate management decisions
•Continual Assessment: Environment, Patient, and Team
‐Knowledge of patients past, present, future
‐Allows paradigm shift when on “wrong path”
•Goal: One Big Picture from many small pieces
•Examples of Situation Awareness
‐Benefited from recognition or challenging recognition

23. Page 22
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Mental Modeling as a tool
•Stating what is known …. Stating what is not known
• … What are we missing
• … This is what we are going to do next
‐May Include Contingencies
•Encompasses other CRM skills
‐Communication: assertive but not authoritarian
‐Team Roles/Leadership:Affect on leader/group emotion
‐Situational Awareness: refines situational awareness/shared cognition
‐ Resource Utilization: allows others to predict what is needed
•Examples

24. Page 23
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Category 4: Situational Awareness

25. Page 24
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Recap: Situational Awareness
• Utilize all available information
• Anticipate and plan for crises
• Use mental modeling to create common
understanding
• Adjust situational awareness when faced with
new information

26. Page 25
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Putting it all together:

27. Page 26
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Overall Impression:
1) How is this applicable to you
2) Is it realistic, is it possible
3) What are the challenges/roadblocks
4) What is next this week and beyond

28. Page 27
xxx00.#####.ppt 7/3/2013 1:16:46 PM
Pediatrics
Questions?