By adapting strategies developed by the aviation industry, RTs can improve care during emergencies

 Since the 1980s, the professional aviation paradigm of crew resource management (CRM) techniques has created and sustained a safety culture that has led—and continues to lead—the way to an overall airline safety record going beyond the industry-desired six-sigma threshold. In the mid 1990s, initial efforts were taken to apply this training to medicine. Since that time, skills for human factors in patient safety have been refined to the point where effective training, with high levels of clinical relevance and efficacy, can influence outcomes. Team training addresses the interpersonal skills that have been identified as causal factors in adverse patient outcomes. Respiratory therapists can initiate the skills training necessary to detect, prioritize, and manage problems and errors in a team-based environment. This training can lead to improvements in care during respiratory emergencies such as difficult intubations.

Each time someone boards a commercial airplane, their personal safety is in the hands of the pilots and other technical and support personnel who make up the crew. These individuals have been specially trained to operate complex equipment, make time-critical decisions, and solve problems in a team-oriented environment in which errors can have fatal consequences. In many ways, respiratory care is similar. The outcomes (and sometimes the very survival) of a patient being cared for by a respiratory therapist depend on the response team’s ability to make the right care decisions at the right time.

In the health care environment, respiratory emergencies are among the most life-threatening situations encountered. Care providers must respond very quickly and with the right choice of equipment used correctly in order to improve or establish an airway. Errors may mean brain damage or death for the patient.

Errors (aside from equipment malfunctions) result from the physiological and psychological limitations of humans. The human factors that contribute to error include fatigue, overwork, fear, cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision-making.

The principles of CRM include situational awareness, crew coordination, and problem-solving using all available resources. They can be applied to the management of respiratory and airway emergencies to provide a strategy—airway resource management (ARM)—that can reduce errors and facilitate the best possible patient outcomes.

The CRM Model in Aviation
As a variation on a common expression goes, mistakes happen. But mistakes made in the cockpit of an airplane can have severe and highly visible consequences for human safety. For this reason, pilot training and certification programs are extensive and taken seriously by individuals and commercial airlines.

Pilot training programs were traditionally focused on the technical aspects of flying and the individual pilot’s performance. With the introduction of flight recorders and cockpit voice recorders into modern aircraft, there have been new insights into the causes of accidents. Information gathered from these devices has indicated that many accidents actually result from breakdowns in human factors as opposed to failures of aircraft-handling skills or a lack of technical knowledge on the part of the crew. For example, inadequate communications between crew members and/or between crew and ground personnel lead in turn to a loss of situational awareness, to a breakdown in teamwork in the aircraft, and ultimately to a bad decision or series of decisions that result in a serious incident or a fatal accident.1

The training that has come to be known as crew resource management was developed in response to this new analysis. Originally, CRM was short for “cockpit resource management,” a term first used in 1977 by aviation psychologist John Lauber, who defined it as “using all the available resources—information, equipment, and people—to achieve safe and efficient flight operations.”2

Error management is the foundation of CRM. A potential error is defined as an action or inaction leading to a deviation from plans or a divergence from team or organizational intentions. Error management is based on understanding the nature and extent of the error or acknowledging the potential of the error, changing the conditions that induce the error, determining behaviors that prevent or rapidly resolve problems, and training personnel accordingly. CRM examines human performance limiters (such as fatigue, stress, hierarchical decision-making, and complete reliance on traditional leadership roles) and the nature of human error, and it defines behaviors that are countermeasures to error, such as leadership, briefings, monitoring and cross-checking, decision-making, and review and modification of plans.

CRM training is now widely used in the aviation industry, typically taking the form of courses lasting several days and emphasized in recurrent training. Often, the training includes monitoring of CRM skills during flight simulation in which trainees experience complex emergency situations and have the opportunity to practice effective crew coordination techniques learned in the classroom. Airway resource management includes the same monitoring during training and assessment of implementation of these skills in patient care.

There is no single defined curriculum for CRM, but all of the following course attributes do apply to emergencies in respiratory care:

Communication/interpersonal skills. These include participation, active listening, feedback, and polite assertiveness. Good communication skills can help the crew to develop a shared mental model of problems that need to be resolved in the course of the flight, thereby enhancing situational awareness.1 In the cockpit, factors such as rank, age, crew position, and cultural differences can create communication barriers. The same factors may impact communication in an airway emergency. CRM training heightens crew members’ awareness of these barriers and how they can be overcome to improve communication.

Situational awareness. This is the ability to accurately perceive what is going on in the cockpit and outside the aircraft. In order to establish situational awareness, people take in information through the five senses. This information is then transformed by the brain into a mental model of the situation, a process known as perception. In any individual, the perceptive process not only depends on current information for its evaluation of the situation but also draws on past experiences and sensations. Perception is therefore a product not only of immediate sensations but also of cultural and social influences acquired through a lifetime of experiences.

Problem-solving, decision-making, and judgment. Problem-solving can be thought of as a cycle of events beginning with information input and ending with making a final decision.

In aviation, thorough preflight planning helps to provide a yardstick against which in-flight decisions can be made. Understanding the plan also allows individual crew members to contribute in the most effective way to decisions made in flight.1

Leadership/“followership” skills. In aviation, there is clear recognition that the command role carries a special responsibility. All decisions must come from the pilot-in-command and be understood and supported by all crew members. Similarly, every noncommand crew member is responsible for actively contributing to the team effort, for monitoring changes in the situation, and for being assertive when necessary.3

Stress management. Stress can be defined as a state of highly unpleasant emotional arousal associated variously with overload, fear, anxiety, anger, and hostility—all of which threaten both individual performance and teamwork. In addition to the stress generated by simply being in an emergency situation, crew members may bring other types of physical and mental stress to the situation that may be difficult for others to detect.

Stress recognition in oneself and others is vital to effective stress management. Several airline operators are attempting to alleviate stress problems by encouraging open and frank communications between operational management and flight crew members, and by viewing stress as part of the fitness-to-fly concept.3

Critiquing skill. This is the ability to analyze a future, current, or past plan of action. In aviation, this would include premission analysis and planning, ongoing review as part of the inflight problem-solving process, and postmission debriefing. This is one area where respiratory therapists may have already participated in CRM techniques, as during a postresuscitation critique of actions and decisions.

 Adapting the CRM Model for Airway Resource Management
Adverse events in the health care environment typically involve only single patients and rarely produce the intense media attention of an aircraft incident. Health care systems, on the national or international level, do not have a standard method for the examination, documentation, and analysis of incidents related to patient care, or specifically to airway management. Nevertheless, individual health care providers and institutions can adopt the proven principles of CRM to improve the utilization of resources and reduce the likelihood of errors during efforts to intubate and/or ventilate patients through a defined strategy for ARM. In developing an ARM strategy, training can be organized along the same curriculum areas, with appropriate modifications for the overall health care environment and for the individual respiratory therapist.

Communication/interpersonal skills. Verbal communication in a forthright and relevant manner increases the likelihood that information will be understood and accepted. Problems can then be anticipated and dealt with appropriately. As in aviation, training should include practice in participation, active listening, feedback, and polite assertiveness. Effective communication also allows problem-solving to be shared among team members by enabling each person to contribute appropriately and effectively to the decision-making process.

Just as in the cockpit, factors such as rank (which in the respiratory therapy arena may translate to credentials, level of training, and experience), age, gender, and cultural differences can create communication barriers. Communication is also affected by individual speech patterns, body language, and grammatical styles. Because of these complexities, the team responding to an airway emergency needs to be aware of and sensitive to the nuances of effective communication.

Situational awareness. The health care team’s accurate perception of the factors and conditions that affect the patient and themselves during a specific respiratory emergency yields situational awareness. An accurate assessment of reality starts with the very basic assumption that it may well not be obvious. The typical intellectual processes of categorizing patterns and rationalizing phenomena to fit with past experiences are inadequate in dealing with the reality of a unique set of circumstances in a rapidly changing environment. In respiratory care, as in aviation, the “know it all before it happens” assumption creates an attitude of complacency, which can prove to be fatal.4

Problem-solving, decision-making, and judgment. As with aviation, planning ahead is critical. The team responding to an emergency within a hospital must be properly prepared for the difficult airway/ventilation problem. This training and preparation include a detailed knowledge of the methods available for both control of the airway and ventilation of the patient. The health care organization must formulate specific policies and procedures, including outlines of expected actions and the level of staff training and education required for those actions. Procedures should include detailed information on equipment and techniques for airway management.

Leadership/followership skills. The health care organization should provide formal training in leadership and teamwork. Operationally, a new team may be formed on every response call, so it is important that the overall organizational culture encourages and fosters a climate in which good teamwork can flourish.

Good communication skills and a clear understanding of the decision-making process are critical components of effective teamwork. Additionally, the ability to resolve conflicts appropriately is important. Conflict is inevitable. In fact, it is often beneficial if handled properly and constructively. Conflict resolution that is focused on the underlying question of who is right is destructive. Conflict resolution that is focused on the question of what is right is helpful. With the right approach, conflict can be transformed into a dynamic comparison of viewpoints that leads to deeper thinking, better problem definition, and sound solutions.

Within each team responding to a cardiopulmonary emergency, there must be a clearly defined leader to address problems related to the airway. With the rotation of duties as the primary emergency team leader during shifts or calls, each individual must have the opportunity to develop the leadership skills required to deal with the challenging airway. Clear performance standards and a nonpunitive approach to error should be established.

Stress management. Stress often arises as a result of a perceived gap between the demands of a situation and an individual’s ability to cope with these demands. As stress involves the processes of perception and evaluation, it affects both the cognitive and interpersonal skills that form the basis of the ARM strategy.

In high-pressure situations, stress can be relieved by establishing priorities and by delegating tasks to other members of the team. This technique can be used successfully only when subordinates have been adequately trained in the cognitive and interpersonal skills that will enable them to take on additional responsibility when circumstances require.

Critiquing skills. Techniques for accomplishing critique vary according to the availability of time, resources, and information. The art of critique is not to dwell on the negative, but to accentuate the positive and to encourage participation from the team.

Although the environment of health care is very different from that of a cockpit, both kinds of teams operate in stressful and sometimes rapidly changing environments in which customers (passengers or patients) are depending on them for their personal safety. Because errors in aviation have been so well researched and comprehensively addressed, respiratory care has much to learn from experiences in the cockpit. The aviation industry’s CRM training concept, which focuses on human factors and how they contribute to errors, offers a valuable model for training in a critical aspect of respiratory care: airway management.

Prior to adapting the principles of crew resource management for an airway resource management strategy, errors must be objectively documented and analyzed. Technical mistakes suggest the need for technical training. Problems related to communication, leadership, and decision-making call for team education and exercises focused on leadership. Procedural errors may result from human limitations or from inadequate procedures that need to be changed. Violations can stem from a culture of noncompliance, perceptions of invulnerability, or poor procedures.

Crew resource management can provide an excellent foundation for an ARM strategy in respiratory care. But just as there is no one standardized course in CRM that is universally accepted and taught throughout the aviation industry, there must be team training in ARM to prepare the team to work together in all types of urgent situations.5 To realize the greatest potential for the principles of CRM to minimize errors in airway management, each health care organization must evaluate its own strengths and weaknesses as an organization. This will require a sincere commitment to analyzing observed errors and dedicating qualified human resources to the development and implementation of training.

Team training and human factors skills are absolutely critical to health care teams that operate in safety-critical environments on a daily basis. In spite of increased automation and the use of technology, individual error remains inevitable due to human limitations constrained by normal everyday stressors such as fatigue and multitasking. When confronted with less than optimal team dynamics, professional cultural differences, unrealistic attitudes, staffing limitations, and other issues, human limitations become constrained even further. The operational world will always be imperfect. Human factors and team training are key to making the clinical workplace safer for staff and for patients. There will always be many factors that create problems and amplify the potential for human error. When health care teams work well together, however, threats and errors can be recognized, prioritized, and managed before an adverse outcome or close call becomes a reality. Creating and sustaining a patient safety culture is the reality and the promise of human factors training.

Dan Hatlestad is president of Clinical Marketing Services, Littleton, Colo.

1. Royal Aeronautical Society. Crew resource management: a paper by the CRM Standing Group of the Royal Aeronautical Society. 1999. Available at:   Accessed January 13, 2005.
2. Lauber J. Resource management in the cockpit. Air Line Pilot. 1984;53:20-3.
3. Naval Aviation Schools Command. Seven skills. Available at:  Accessed January 21, 2005.
4. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. International Journal of Aviation Psychology. 1999;9(1):19-32. Available at:   Accessed January 21, 2005.
5. Human Performance Training Institute. Available at:   Accessed January 13, 2005.