Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents*

Management of inpatient emergencies (including “codes”) in teaching hospitals is often the responsibility of trainees in internal medicine. In such settings, successful implementation of therapeutic plans requires a technically competent leader who is able to coordinate the entire team’s effort. Leadership requires acquiring and interpreting patient information, choosing and prioritizing tasks to be accomplished, assigning them to specific individuals, and repeatedly reevaluating the results of therapy. Most residencies do not offer systematic training in crisis management leadership beyond limited portions of advanced cardiac life support certification. Crisis management skills are important in other medical fields, and specialized simulation-based curricula have been used in these settings for some time (1– 6). Members of our group pioneered the development of crisis-management and teamwork training for anesthesiologists based in part on the curriculum of Crew Resource Management (CRM) taught in commercial aviation. In the 1980s, research in aviation demonstrated that a large proportion of aircraft accidents were linked to failures on the part of crews with appropriate technical skills to manage their resources effectively (7). In an effort to address the shortcomings of decision-making and teamwork skills of cockpit crews, airlines in the United States joined with NASA and the U.S. military in establishing CRM training (8). Similarly, in health care, many accidents seemed due to nontechnical aspects of the work of individuals, teams, and systems. Thus, by analogy to the aviation curriculum, the Anesthesia Crisis Resource Management (ACRM) course developed in 1990 emphasizes nontechnical skills of decision making and team and resource management (2, 9) (Table 1). A textbook on the principles of CRM in anesthesiology (with content highly applicable to critical care) has been available since 1994 (2). The decision-making components of critical care deal with cognition in highly dynamic environments that differ from those encountered in the outpatient clinic or the wards. In such environments, diagnosis, monitoring, and therapy are completely interleaved and iterated rapidly, often including hands-on implementation by an integrated team rather than simply writing orders for later execution. In these dynamic settings, issues of allocation of attention, use of redundant information, and repeated situational reevaluation are paramount. The team and resource management components deal with the ability to translate the knowledge of what needs to be done into effective team activity in the complex and ill-structured real world of an intensive care unit (ICU) or ward emergency response team. Here, issues of leadership and followership are important, combined with the communication skills needed to create effective teamwork. Being able to identify, mobilize, and use the technical, human, and organizational resources of the ICU and the hospital is crucial. CRM-based simulation training for anesthesiologists and other medical specialties has spread widely since 1990, being adopted most notably at Stanford and Harvard in the United States and at a number of centers around the world, including centers in the United Kingdom, Australia, New Zealand, Switzerland, Denmark, and Germany (6, 10–16). The ACRM-like approach has been codified, and specialized instructor training programs are offered by the initial centers of excellence (4, 17). Other approaches to applying CRM to health care also have been described, such as Team Oriented Medical Simulation (18, 19). To date, a simulation-based crisis management curriculum has not been offered to internal medicine house staff in the intensive care setting. We describe the initial evaluation of a crisis management curriculum that has been taught during our medical surgical ICU rotation for the past 2 yrs. The major goal of the course is to combine didactic teaching with an experience representing what a practitioner might encounter in a real medical setting. Four elements were essential: a) providing a reasonable replica of both the human aspects and physical environment surrounding medical emergencies; b) presenting “cases” that challenge both the medical and nontechnical skills of trainees; c) allowing residents to experience managing the cases themselves without direction from an expert attending; and d) providing participants with detailed review of their performance, using self-critique by the individuals involved, their peer group, and expert instructors. The title of the course is Improving Management of Patient Emergency Situations (IMPES). *See also p. 2553. From the Department of Anesthesia, Stanford University Medical Center, Stanford, CA, and the Department of Anesthesia, VA Palo Alto Health Care System, Palo Alto, CA. Copyright © 2003 by Lippincott Williams & Wilkins