Book of the month: Crisis Management in Acute Care Settings (2nd ed) by St.Pierre, Hofinger, Buerschaper and Simon

The last two books reviewed here: "Why we make mistakes" and "Set phasers on stun" were light summer reading. "Crisis Management in Acute Care Settings" is the sort of book you need the rainy weather and darker evenings for; its 335 pages of densely packed text require concentration and persistence.

The four authors are: Michael St.Pierre (Anaesthetist, 'Oberarzt' at Erlangen University hospital), Gesine Hofinger (PhD, Cognitive Psychologist, Department of Intercultural Business Communication, Friedrich-Schiller-University, Jena), Cornelius Buerschaper (Researcher, focused on decision-making in crises, who unfortunately passed away in August 2011) and Robert Simon (Director of Center for Medical Education, Harvard Medical School)

Who should read this book?

This book is for the dedicated human factors and/or simulation devotee. Although an aim of the authors was to "formulate the text in an easy to read language" (p.ix) with a target audience of "nurses, technicians, paramedics and physicians" (p.ix) the language used is at times overly complex and the concepts require a more than basic understanding of human factors. This is not the book to give to people who have expressed an initial interest in human factors or simulation.

I haven't got time to read 335 pages...

The book is divided into four parts, so you can decide if there is one particular aspect you wish to explore:

1. Basic Principles: Error, Complexity and Human Behaviour (81 pages)
2. Individual Factors of Behaviour (111 pages)
3. The Team (81 pages)
4. The Organization (62 pages)

62 pages? That's still too much!

Every chapter finishes with an "In a nutshell" section which provides an overview of the content. It may therefore be worthwhile reading the "nutshells" and then deciding which chapters warrant a more detailed look.

What's bad about this book?

There are a number of minor annoyances such as:

• Random use of italics e.g. "First, the majority of patients arrive at the ED rather unprepared..." (p.12)
• Obtuse sentences e.g. "Humans try to balance actual and nominal physiological conditions"(p.66) "The interpretation of sensory impressions tries to form them as good a good Gestalt (the law of "Praegnanz" - good form)."(p.93)
• Obtuse sentences which are also long e.g. "From an evolutionary point of view, the ability to rapidly produce workable patterns to understand of the environment seems to have been advantageous compared with a 100% scanning and consciously filtering important from unimportant information about the surroundings."(p.95) Including possibly the longest sentence I have ever read: "As complex situations are characterised by the interrelatedness of many system variables (on-scene situation, pathophysiology of the patient, main motives of the different providers and professional groups involved), there will be some goals which are in themselves justified but which are mutually exclusive - be it the parallel technical and medical rescue operation on site or the side by side of diagnostic and therapy during resuscitation of a trauma patient in the emergency room."(p.127)
• The use of distracting background pictures in diagrams which add nothing to the understanding of the text (p.90,p.188)

A more important oversight is the lack of any reference to our acute medicine and surgical colleagues whom I would consider part of the "acute care setting". With the advent of Non-Technical Skills for Surgeons (NOTSS), the development of courses looking at surgical crisis teamwork and leadership and courses for acute medical practitioners, I would like to see surgeons and acute physicians included in the third edition.

What's good about this book?

This book provides a detailed analysis of human factors and team psychology in a high stakes environment. The book also links the aforementioned with patient safety and so enriches the understanding one may have of how work in human factors/simulation can improve patient safety.

The "in a nutshell" section at the end of every chapter is a useful reminder of what has been discussed. Most chapters also have a "tips for clinical practice" section which may help to convert theory into practice and there is an extensive list of references provided for every chapter.

Most chapters are packed full of information and, once the convoluted language has been overcome (see above), they begin with a good overview of the concepts and then delve into the core of the matter, focusing on each piece in turn.
For example, Chapter 11: "The Key to Success: Teamwork" discusses and defines teamwork and teams, followed by a review of team performance. The latter is analysed by looking at the input into the team from: individual characteristics, team characteristics, characteristics of the task and characteristics of the environment. The authors then go on to discuss how teams are formed, how a "good" team performs and where teams can go wrong (communication, shared misconceptions, groupthink etc. etc.) The level of detail is extremely impressive and educational. The same detail is found other chapters such as chapter 3 which looks at the nature of error and chapter 9 which looks at stress (acute, chronic, coping mechanisms). 

There are also some great quotes such as:

• A situation does not cause emotions; your interpretation of the situation causes emotions (p.99) (with echoes of Jack Sparrow)
• "As an overall philosophy, it is wise to use good judgment to avoid situations in which superior clinical skills must be applied to ensure safety"(Attributed to Hawkins in Human Factors in Flight, 1987) (p.118)
• ...human factors should never be equated with "risk factors." Each time mindful healthcare professionals detect, diagnose, and correct a critical situation or an error before it has an opportunity to unfold, it is the human factors that prevent patient harm (p.15)
• The development of expertise requires struggle. There are no shortcuts (p.33)
• Practice does not make perfect; instead perfect practice makes perfect (p.33)
• Teamwork is not an automatic consequence of placing healthcare professionals together in the same shift or room (p.210)
• If you want to profit from a good team process in a critical situation, you need to rehearse team skills on a frequent basis. (p.216)
• You will not succeed if you do not talk! Talking is the way team members develop and maintain a shared mental model. (p.217)
• Teamwork seems to be the essential component in the pursuit of achieving high reliability in healthcare organisations. (p.324)

Final thoughts

Buy this book for your simulation centre. Set aside the time to read it. It is a great reference text and will inform your workshops, lectures, research, simulated scenarios and your clinical practice.