Administration and Leadership, Columns, Patient Care

Crew Resource Management Can Improve Crew Efficiency

Issue 5 and Volume 40.

The patient is in cardiac arrest. Bystanders began CPR prior to EMS arrival and the estimated down time for the patient is less than 10 minutes. On scene, there’s an ambulance crew with an EMT and a paramedic. The volunteer fire department also responds with two EMTs, one of whom just obtained their initial certification.

Upon arrival, the EMS team takes over CPR and performs it via accepted guidelines: hard and fast at 100 compressions per minute. A few times, the paramedic has to remind the new EMT to push faster. Pulses can be felt with compressions, so the paramedic elects to intubate the patient, which allows for continual compressions and measurement of waveform capnography, and the initial reading is 12 mmHg. The patient is defibrillated twice and receives a total of 3 mg of epinephrine and 300 mg of amiodorone via IV.

An organized rhythm appears on the cardiac monitor but the paramedic assesses the patient and identifies no palpable pulses. After several more minutes of CPR, the paramedic states resuscitation attempts should stop, once again assessing and finding no palpable pulse without compressions. Others on the EMS team nod in acknowledgment and begin turning off monitors, stopping IV flow and disconnecting ECG leads. Obviously affected by witnessing their first cardiac arrest, the new EMT places their fingers to the patient’s neck and states, “I think I feel a pulse.”

How should the crew respond and what should happen to the rookie EMT who spoke up? The answer is simple. The initial response of the EMS crew is to reevaluate the patient to see if there are palpable pulses and then respond accordingly. As for the new EMT, way to go!

Discussion

The paramedic was in charge of orchestrating care. The EMTs were doing CPR and ventilation, and advanced skills were done by the other paramedic, who coached the new EMT to ensure effective CPR. This is good. In fact, any member of the team should be able to speak up if a skill isn’t being performed correctly or if they recognize a potential error about to occur.

The term used to describe this team dynamic is crew resource management (CRM). Pre- assignment of team roles is a component of CRM, but not the only one. The goal is safety and the reduction of errors, all hopefully adding up to a good patient outcome. Let’s replay the call and see what CRM may look like.

Using a CRM model, each member of the team has assigned roles. There’s no guessing or lobbying when the crew arrives to see who gets to do what. The paramedic on the call is the highest trained, so it’s logical they’re the team leader. The team leader should routinely request feedback from others on the team regarding their individual tasks. For example, the paramedic should ask the EMT providing ventilation if the patient is easy to ventilate and if they’re getting good chest rise and fall. This information will help the team leader make a decision about the course of care–advanced airway or continue with bag-valve mask. When providers change their role as compressor for CPR, they should monitor each other to ensure compressions are at the proper rate and depth. When the paramedic prepares to administer a medication, the drug and dose should be confirmed by other providers on scene. For example, when the paramedic removes a vial of amiodorone from the med kit, they should read the vial and confirm the medication is amiodorone. The vial should then be handed to one of the EMTs and they should be asked, “This is amiodorone. Do you agree?” The EMT should verify and respond by saying, “Yes, I agree, this is amiodorone.” After the medication has been administered, the paramedic can once again confirm with the EMT it was amiodorone that was administered to the patient by showing them the empty vial.

When the paramedic believes that further resuscitation attempts are futile, they should ask the rest of the team, “Does anyone have any suggestions or thoughts about things we may have missed?” The team should voice any thoughts or ideas they have about the continuation of care before all agreeing whether or not to terminate the arrest. When resuscitation is terminated, the paramedic should ask others on the team to verify the absence of pulses without compressions. Afterward, the entire EMS team should discuss the call and how it went, including thoughts about improving team performance in the future.

Conclusion

This description of team interaction may sound tedious and unnecessary–the suggestion of the paramedic verifying a medication with the EMT may sound weird–but it’s better practice than what we’ve been doing for years. Regular practice of the CRM model can improve the efficiency of care delivery and potentially patient outcomes. It’s better to be safe than sorry.