Ethan is a newly qualified paramedic working for a state ambulance service. He has been sent to work at a station he has not worked at before and with a paramedic he has never met. Almost immediately after he arrives at work, the crew is despatched to an emergency call for a male with shortness of breath and chest pain. On the way to the call, both crew members have considered what might be causing the chest pain which allows them to be prepared and make the necessary decisions in a timely manner. On arrival at the scene, the crew members both engage in a process of history-taking and differential diagnosis, and find it difficult to agree upon a cause of the chest pain and shortness of breath. Ethan believes that the patient should be carried to the ambulance in a carry chair, whereas the other more experienced paramedic states that the symptoms are not cardiac in nature and the shortness of breath is mild enough for the patient to walk the short distance to the ambulance.
Crew resource management
Pre-hospital care providers work in highly unpredictable environments in which they provide urgent medical care, often involving long, irregular hours and sometimes exposure to physical danger (Carhart, 2012). Greater discussion in crew resource management (CRM) and its relationship to paramedic patient care is required.
The current article discusses and provides recognition of some of the factors impacting safe paramedic practice and provides a synopsis of CRM. The authors present one conceptual model, the Egg Timer Model of Disparity designed by Willis and published in Summers and Willis (2010), as a starting point for paramedics to consider, which can aid safe practice.
Adverse events in pre-hospital care
The early work of James Reason (1995) was seminal in identifying the concept of adverse events and human error within healthcare environments. Reason categorised error by either:
While in-depth descriptions of each of these are too comprehensive to be included in the current short article, Reason's analysis has relevance to paramedicine. In particular, human rather than equipment failure represents the greatest hazard to patient care; errors occur at all levels of the organisational hierarchy; and paramedics do not work in isolation. A snapshot of such errors specific to pre-hospital care is summarised in Table 1.
| Condition | Example |
|---|---|
| Unfamiliarity with the task | Paramedics are routinely faced with new situations or medical conditions they have never experienced before and are expected to safely triage and manage these cases in a timely manner |
| Time shortage | During a time-critical situation, every second counts, e.g. having to apply clinical skills much quicker than in non-time-critical situations, or even when having to travel to an incident under emergency conditions |
| Excessive noise | Typical background noises include relatives and family members, TV, police radios, and traffic |
| Poor human system interface | A badly laid-out ambulance will prevent paramedics treating their patients safely any may also place themselves at risk |
| Information overload | Receiving large volumes of personal information, such as medical history from a patient, or being required to complete several complex tasks all at the same time |
| Misperception of risk | Demonstrating a complacent attitude towards risky tasks |
| Inexperience—not lack of training | Not having had significant exposure to both high- and low-acuity cases |
| Poor instructions or procedures | During training to use a piece of equipment from the ambulance education/leadership team, or from a crew member when a paramedic asks a junior team member to help during a patient care intervention without providing clear instructions of what is required |
| Inadequate checking | Examples include not undertaking thorough safety checks when administering drugs, or applying a piece of equipment to a patient, such as a traction splint, when the paramedic hasn't used it for some time |
| Educational mismatch of person with task | Asking a clinician to perform a task who has not been trained in that task, e.g. a paramedic asking a lower ranking clinician to site an intravenous (IV) line |
| Distributed sleep patterns | Inadequate amount of sleep in quality or time prior to the shift commencing |
| Hostile environment | Created by staff or by members of the public |
| Monotony and boredom | When sitting on standby, or on station waiting for the next call |
Impact of CRM
Aviation is well known for its strong identification, research, investigation and management of human error and CRM training. CRM stemmed from National Aeronautics and Space Administration (NASA) workshops in 1979, and is now embedded within all pilot training programmes (Summers and Willis, 2010). Flin et al (2002) provide this definition:
‘CRM focuses on “non-technical skills” critical for enhanced operational performance, such as leadership, situation awareness, decision making, team work and communication.’
Today, evidence of human error and the ability to investigate and manage it has seen CRM programmes emerge in a broad range of professional disciplines such as aviation, engineering, Formula One, and health care. In essence, CRM focuses on:
Much of this is termed as non-technical skills. Shields (2011) defines non-technical skills as cognitive and social skills combined with technical skills, allowing for safe practice. Gangaram et al (2017) go further, suggesting that non-technical skills include effective teamwork and communication which are key to CRM.
There has been an increased uptake of CRM in health care as a means of addressing complex human factor (HF) challenges that present in the acute care setting. These carry high-cost consequences in areas such as emergency medicine, intensive care, midwifery and surgery. The meta-analysis reported by O'Dea et al (2015) summarised 20 articles published between 1985 and 2013 to establish if CRM had any effects on reactions, learning, behaviour and clinical care outcomes in acute health-care settings. The findings showed that CRM training positively affected teamwork, but cautioned that more research was required to find a correlation between CRM and other health domains.
Even though CRM in health care is developing, there remains a paucity of research concerning CRM in paramedicine—despite the link between CRM development in aviation and paramedicine being relatively close. Summers and Willis (2010) and Lambert (2009) highlight that pilots and paramedics struggle with similar issues: both are vulnerable to unpredictable and at times uncontrolled environments where the cost of error is high.
Shaban et al (2004) highlight the need for a theoretical framework that investigates the HF inherent in the non-technical skills situated in paramedicine. Shaban et al (2004) elucidates the works of Reason (1995) as having potential uses, yet cautions the general nature of the frameworks. Interestingly, Summers and Willis’ (2010) Egg Timer Model of Disparity provides an exploratory conceptual model of the CRM interface in pre-hospital care and with relevance to non-technical skills. The work of Summers and Willis (2010) highlights that it is not uncommon for paramedics to work with colleagues they have never met before. Considering the spectrum of uncertainty that can surround pre-hospital care contexts, different values and beliefs can have a negative effect on co-judgement and decision-making. For example, walking into a situation that has many unpredictable variables already, even before adding the differences in values among staff. Summers and Willis’ Egg Timer Model of Disparity represents this circumstance and provides a foundation of linking HF and CRM to patient outcomes.
To summarise, the model assumes that the potential of disagreement and uncertainty in judgments and decisions precedes patient contact. This is in part a result of individual experiences, thoughts, and beliefs about the forthcoming emergency or care event. On arrival, thought processes and judgment times can be compressed as a result of the extremes of the patient environment, leading to poor or conflicting decision-making—a state of disparity. Negotiation or settlement of disparate judgements and decisions occur, leading to a positive patient outcome. However, the inability to overcome disparity holds the potential for human error.
Education and research
Paramedic education providers play a key role in instilling a CRM mindset into the future workforce. Paramedicine must discover new ways of preparing future colleagues that are context- and situation-specific. While paramedic education occurs in a wide variety of settings, commonalities of practice exist. The impetus to provide a common and cogent framework addressing human error specific to pre-hospital care is obvious. Curriculum design should inherently have models of CRM which allows students to scaffold and build their education and practice. Such models cannot be simply borrowed from other disciplines.
The Egg Timer Model of Disparity (Figure 1) is a response to a lack of conceptual modelling. It answers ‘how and why’ medical errors occur in paramedicine, particularly those errors relevant to non-technical skills. As this line of study has not been researched before, the Egg Timer Model of Disparity provides an exploratory basis upon which to examine HF variables, CRM initiatives and their impact on patient care.
Conclusion
Crew resource management is concerned with examining the safe performance of people at work. CRM acknowledges that personal, organisational and environmental influences all play a part in human error and seeks to resolve such matters through a comprehensive education and training programme. Paramedics are all too often affected by their environment as they operate in a series of complex, demanding, and high-stake settings. CRM programmes can provide paramedicine with the disciplines of error identification and minimisation while they undertake their duties. More can be done to include CRM training in paramedic education programmes. This will ultimately translate into practitioners having a deeper understanding of the effects of influences on safe practice.
The article posits that a discipline-specific conceptual framework and model of the CRM interface is required to meet the high-risk demands of paramedicine. The Egg Timer Model of Disparity by Summers and Willis (2010) is one model that has the potential to uncover the situation-specific context of HF and CRM in paramedicine. Furthermore, such a model provides a research and educational scaffold upon which to build a picture of the HF phenomena in the pre-hospital care environment.