Airway & Respiratory, Columns, Patient Care

EMS Improves with Crew Resource Management Training

Issue 4 and Volume 40.

Structured Crew Interaction

O’Dea A, O’Connor P, Keogh I. A meta-analysis of the effectiveness of crew resource management training in acute care domains. Postgrad Med J. 2014;90(1070):699–708.

This month we focus on a meta-analysis report. This is a systematic review of all available evidence to help healthcare professionals make evidence-based care and guideline revisions. These reviews have become increasingly important as we try to make sense of studies and weigh their validity.

EMS shares many characteristics with high-risk and unpredictable work environments, like aviation, healthcare and the military. In these high-risk environments, errors can cause great harm to the patient and clinicians.

Crew resource management (CRM) is a structured way for groups to effectively communicate, improve teamwork and reduce errors. CRM training enhances situational awareness, communication, safety, leadership and problem-solving skills. The training was first developed by NASA after several disastrous airline crashes revealed that 60–80% of crashes were due to human error. CRM has been adopted by all military branches as well as the International Association of Fire Chiefs.

In healthcare, the Department of Defense and the Agency for Healthcare Research and Quality have adapted CRM principles into a complete training program called TeamSTEPPS. The National Registry of EMTs has incorporated it into the new Paramedic Psychomotor Competency Portfolio, and will be testing candidates in a scenario format, including their use of CRM, as early as 2016.

In the article we’re reviewing this month, Paul O’Connor, MD, and his associates from the National University of Ireland, performed a meta-analysis of articles that evaluated the implementation of CRM training in the acute care setting of healthcare.

Data: By reviewing 20 articles from a pool of 6,648, published from 1985–2013, researchers hoped to identify if CRM training improved any of the following measures within the healthcare system: reactions, learning, behavior and clinical care outcomes. These measures make up an evaluation hierarchy, developed by Donald Kirkpatrick, MD, and is used to gauge the success of a training method. In this case, “results” is replaced with clinical care outcomes.

Of the 20 articles, training time ranged from as little as an hour and a half to as much as two days. Staff members and interns from surgical care, obstetrics, neonatal care and members of a trauma team participated in the training.

Outcomes: Using a five-point scale, nine of the articles showed the training was considered useful. Three separate studies reported a gain in knowledge from all employees, based on multiple-choice and short-answer tests. Despite being just three studies, the information gathered included 372 respondents. None of the studies showed a net loss in knowledge.

The largest noted difference was in behavior. Eight assessments evaluated the pre-training and post-training behavior as a team member; an important element of CRM is to function as a team irrespective of title or leadership. All eight studies showed a growth in team behavior.

Only three studies evaluated clinical care outcomes. Based on the difference in measured outcomes and other non-controlled factors, the authors were unable to determine if CRM had an impact on this measure.

Discussion: This type of review is very helpful as EMS continues its journey toward an improved culture of safety. While each of the studies have their own merits and individual strengths, when combined they build a bigger picture showing CRM works to improve teamwork, communication and safety.

CRM has a powerful effect on knowledge and behavior, and a smaller effect on safety attitudes. TeamSTEPPS was found to offer some of the best standardization and large-scale opportunity for more research. More research is needed to better understand CRM’s impact on patient care outcomes, but we’re confident we’ll see positive changes when such research is presented.

Bottom line

What we already know: CRM training has been shown to decrease errors and improve teamwork.

What this study adds: Evidence now suggests research of CRM’s effectiveness in healthcare surpasses that of research of CRM in aviation. EMS providers, educators and leaders should be reviewing and using CRM techniques.

Visit www.pcrfpodcast.org for audio commentary.