Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study.

BACKGROUND: Human factors account for the majority of adverse events in both aviation and medicine. Human factors awareness training entitled "Crew Resource Management (CRM)" is associated with improved aviation safety. We determined whether implementation of CRM impacts outcome in critically ill patients. METHODS: We performed a prospective 3-year cohort study in a 32-bed ICU, admitting 2500-3000 patients yearly. At the end of the baseline year, all personnel received CRM training, followed by 1 year of implementation. The third year was defined as the clinical effect year. All 7271 patients admitted to the ICU in the study period were included. The primary outcome measure was ICU complication rate. Secondary outcome measures were ICU and hospital length of stay, and standardized mortality ratio. RESULTS: Occurrence of serious complications was 67.1/1000 patients and 66.4/1000 patients during the baseline and implementation year respectively, decreasing to 50.9/1000 patients in the post-implementation year (P = 0.03). Adjusted odds ratios for occurrence of complications were 0.92 (95% CI 0.71-1.19, P = 0.52) and 0.66 (95% CI 0.51-0.87, P = 0.003) in the implementation and post-implementation year. The incidence of cardiac arrests was 9.2/1000 patients and 8.3/1000 patients during the baseline and implementation year, decreasing to 3.5/1000 patients (P = 0.04) in the post-implementation year, while cardiopulmonary resuscitation success rate increased from 19% to 55% and 67% (P = 0.02). Standardized mortality ratio decreased from 0.72 (95% CI 0.63-0.81) in the baseline year to 0.60 (95% CI 0.53-0.67) in the post-implementation year (P = 0.04). CONCLUSION: Our data indicate an association between CRM implementation and reduction in serious complications and lower mortality in critically ill patients.

[Damage control surgery in polytraumatized patients]. / 'Damage control surgery' bij polytraumapatiënten.

Care for the polytraumatized patient in the pre-hospital phase has improved rapidly in recent years. This has resulted in more patients being alive on arrival at the hospital. The treatment of polytraumatized patients requires a different approach to that of regular trauma patients because they are threatened not only by the injuries themselves but also by the metabolic disruptions that follow. Therefore, the concept of damage control surgery (DCS) has been developed with the primary aim of controlling the life-threatening situation without immediate definitive repair of the sustained injuries. DCS describes a triphasic approach for abdominal and thoracic injuries and for injuries of the pelvic and extremities. The first phase aims at surgical intervention to stop the bleeding and to prevent further contamination. The second phase consists of resuscitation on the Intensive Care Unit and the third phase aims at definitive repair of the sustained injuries. Despite the low level of evidence found in the literature, DCS seems to reduce mortality rates in polytraumatized patients. Therefore, when initiated correctly and at the right moment, it appears to be a promising technique.