ANESTHESIA CRISIS RESOURCE MANAGEMENT

In 1989, based on the cognitive process model presented in Chapter 83 and the research results of Cooper and colleagues,^[37] Gaba, Fish, and Howard of the VA-Stanford group identified gaps in the training of anesthesiologists regarding several critical aspects of decision making and crisis management that were not systematically taught during standard residency or postgraduate education. These gaps were (1) inadequate learning of precompiled plans for dealing with perioperative events, (2) inadequate skills of metacognition and allocation of attention, and (3) inadequate skill in resource management behavior, including leadership, communication, workload management, monitoring, and cross-checking of all available information. Historically, it had been assumed that anesthetists would acquire these plans and skills "by osmosis," solely by experience and by observing role models who had these qualities. As indicated in a previous section, the aviation domain had learned that such skills were not acquired unless specifically taught, and crisis resource management (CRM) training was created to address these issues for flight crews. The VA-Stanford group modeled their ACRM training^[38] after CRM. To target the identified gaps in anesthesia training, approximately 40% of the emphasis of ACRM is on the medical and technical management of specific high-risk perioperative situations, but at least 60% of the emphasis is on generic principles of crisis management that apply to nearly every complex patient care situation. The key teaching points of ACRM are shown in Table 84-5 .

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The ACRM curriculum uses several teaching modalities to achieve these goals, including

1. A comprehensive textbook on anesthesia crisis management (Crisis Management in Anesthesiology^[39] ). This book includes didactic material on ACRM principles, as well as a comprehensive catalog of critical incidents in anesthesia that provides guidelines for preventing, recognizing, and managing 83 perioperative situations in a uniform format. The catalog section of the text is intended to provide study material to increase anesthetists' stock of precompiled response plans to common and uncommon situations. This textbook has been translated into Japanese and German (by one of this chapter's coauthors).
2. A brief presentation reviewing the principles of ACRM and anesthesia safety.
3. Analysis of a videotape of an aviation accident.
4. Small group exercises analyzing a videotape of an actual anesthetic mishap or analyzing written or video presentations about difficult cases.
5. Several hours of complex multifaceted realistic simulations in which training participants rotate through different roles, including primary anesthesiologist, first responder (called "cold" with no knowledge of the situation), and scrub nurse. Other personnel play the roles of surgeons, nurses, and technicians as in a real OR. Each situation is followed by a detailed debriefing with video feedback. A recent study by Byrne and coworkers demonstrated a positive effect of even an uninstructed videotape feedback.^[40] The debriefing lasts about the same time as the situation itself, and an experienced instructor leads the group to apply ACRM principles in analyzing their own performance. The debriefing session is believed to be one of the most important parts of realistic simulator training; that is, when the actions and behavior (of oneself and the other participants) are considered, critical learning takes place.^{[41] [42] [43] [44]}

Several publications have detailed the response of participants with varying levels of experience to ACRM training.^{[38] [45] [46] [47] [48]} Participants have been extremely positive about their experience in the ACRM course, and most believe that it contributes to their safe practice of anesthesia ( Table 84-6 ).

At VA-Stanford, ACRM has been extended to a multilevel course conducted over a period of several years (i.e., ACRM 1, 2, 3). As the course levels progress, the scenarios become more complex and involve subspecialties of anesthesia. In addition, additional teaching modules cover other important aspects of organizational safety such as "systems thinking" in morbidity and mortality conference settings or peer review settings, follow-up response to severe adverse perioperative events, and disclosure to the patient or family of "bad news" after an adverse event.

In addition to the inventors of ACRM at the VA-Stanford Simulation Center, many other simulation centers have adopted ACRM as a major focus of their training (in the United States, most notably the Boston Center for Medical Simulation, and extensively in Australia, the United Kingdom, and Germany).^{[45] [46] [49] [50] [51] [52] [53] [54] [55]}

Several variant curricula similar to ACRM have been developed on the basis of the textbook Crisis Management in Anesthesiology and the original ACRM experiences. Such experiences include crisis management training at

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By year 2000, ACRM courses and ACRM-like variants were being offered worldwide and formed the quasi-de facto standard for realistic simulator courses. The German Society for Anesthesiology recently released their "Standards and Requirements for Qualified Simulator Training"^[59] (an English version is available at www.medizin.uni-tuebingen.de/psz/english/ until it is published in an international journal) and stated in the preface, "ACRM techniques applied to full scale patient simulators should allow creating a training format to systematically minimize human factors as the main cause of anaesthesia related morbidity and mortality."

In Denmark, ACRM-like training courses are a legal requirement for nurse anesthetists (3-day course) and first-year (2-day course) and third-year residents (4-day course), in addition to some other simulator training courses (e.g., difficult airway). Further plans are being made to require simulation training for intensive care and recovery room nurses, as well as intensive care residents. In London, residents are required to attend one ACRM course during their residency.

Interest in ACRM is growing, but because it is very complex, special training for ACRM instructors has been developed by the Working Group on Crisis Management Training in Health Care (composed of the three pioneering centers in the development of ACRM: VA-Stanford Simulation Center, the Boston Anesthesia Simulation Center, and the Canadian Simulation Centre). This working group has developed and tested a 3-day ACRM instructor training course,^[60] and it has produced a 150-page training manual for ACRM instructor candidates. Experience with the instructor training course suggests that the most difficult aspect of ACRM instructing is "debriefing," and new instructors require a significant period of experience, preferably under supervision by more senior instructors, before being ready to be fully independent ACRM instructors. ACRM instructor training continues at these three centers under the auspices of the working group, and several additional centers trained by the working group are now authorized to conduct their own instructor training.

The working group has promulgated a set of criteria to be met by a curriculum to be called "ACRM" or "ACRM-like." An excerpt of the criteria is shown in Table 84-7 . The full set of criteria is available at http://anesthesia.stanford.edu/VASimulator/ACRM_Criteria.htm.