Debriefing after resuscitation

An evaluation of three methods of in-hospital cardiac arrest educational debriefing: The cardiopulmonary resuscitation debriefing study

BACKGROUND

The use of cardiac arrest educational debriefing has been associated with improvements in cardiopulmonary resuscitation (CPR) quality and patient outcome. The practical challenges associated with delivering some debriefing approaches may not be generalisable to the UK health setting. The aim of this study was to evaluate the deliverability and effectiveness of three cardiac arrest debriefing approaches that were tailored to UK working practice.

METHODS

We undertook a before/after study at three hospital sites. During the post-intervention period of the study, three cardiac arrest educational debriefing models were implemented at study hospitals (one model per hospital). To evaluate the effectiveness of the interventions, CPR quality and patient outcome data were collected from consecutive adult cardiac arrest events attended by the hospital cardiac arrest team. The primary outcome was chest compression depth.

RESULTS

Between November 2011 and July 2014, 1198 cardiac arrest events were eligible for study inclusion (782 pre-intervention; 416 post-intervention). The quality of CPR was high at baseline. During the post-intervention period, cardiac arrest debriefing interventions were delivered to 191 clinicians on 344 occasions. Debriefing interventions were deliverable in practice, but were not associated with a clinically important improvement in CPR quality. The interventions had no effect on patient outcome.

CONCLUSION

The delivery of these cardiac arrest educational debriefing strategies was feasible, but did not have a large effect on CPR quality. This may be attributable to the high-quality of CPR being delivered in study hospitals at baseline.

TRIAL REGISTRATION

ISRCTN39758339.

The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for In-Hospital Cardiac Arrest: The Cardiopulmonary Resuscitation Quality Improvement Initiative

OBJECTIVE

To evaluate the effect of implementing real-time audiovisual feedback with and without postevent debriefing on survival and quality of cardiopulmonary resuscitation quality at in-hospital cardiac arrest.

DESIGN

A two-phase, multicentre prospective cohort study.

SETTING

Three UK hospitals, all part of one National Health Service Acute Trust.

PATIENTS

One thousand three hundred and ninety-five adult patients who sustained an in-hospital cardiac arrest at the study hospitals and were treated by hospital emergency teams between November 2009 and May 2013.

INTERVENTIONS

During phase 1, quality of cardiopulmonary resuscitation and patient outcomes were measured with no intervention implemented. During phase 2, staff at hospital 1 received real-time audiovisual feedback, whereas staff at hospital 2 received real-time audiovisual feedback supplemented by postevent debriefing. No intervention was implemented at hospital 3 during phase 2.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was return of spontaneous circulation. Secondary endpoints included other patient-focused outcomes, such as survival to hospital discharge, and process-focused outcomes, such as chest compression depth. Random-effect logistic and linear regression models, adjusted for baseline patient characteristics, were used to analyze the effect of the interventions on study outcomes. In comparison with no intervention, neither real-time audiovisual feedback (adjusted odds ratio, 0.62; 95% CI, 0.31-1.22; p=0.17) nor real-time audiovisual feedback supplemented by postevent debriefing (adjusted odds ratio, 0.65; 95% CI, 0.35-1.21; p=0.17) was associated with a statistically significant improvement in return of spontaneous circulation or any process-focused outcome. Despite this, there was evidence of a system-wide improvement in phase 2, leading to improvements in return of spontaneous circulation (adjusted odds ratio, 1.87; 95% CI, 1.06-3.30; p=0.03) and process-focused outcomes.

CONCLUSIONS

Implementation of real-time audiovisual feedback with or without postevent debriefing did not lead to a measured improvement in patient or process-focused outcomes at individual hospital sites. However, there was an unexplained system-wide improvement in return of spontaneous circulation and process-focused outcomes during the second phase of the study.

Six habits to enhance MET performance under stress: A discussion paper reviewing team mechanisms for improved patient outcomes

Effective team decision making has the potential to improve the quality of health care outcomes. Medical Emergency Teams (METs), a specific type of team led by either critical care nurses or physicians, must respond to and improve the outcomes of deteriorating patients. METs routinely make decisions under conditions of uncertainty and suboptimal care outcomes still occur. In response, the development and use of Shared Mental Models (SMMs), which have been shown to promote higher team performance under stress, may enhance patient outcomes. This discussion paper specifically focuses on the development and use of SMMs in the context of METs. Within this process, the psychological mechanisms promoting enhanced team performance are examined and the utility of this model is discussed through the narrative of six habits applied to MET interactions. A two stage, reciprocal model of both nonanalytic decision making within the acute care environment and analytic decision making during reflective action learning was developed. These habits are explored within the context of a MET, illustrating how applying SMMs and action learning processes may enhance team-based problem solving under stress. Based on this model, we make recommendations to enhance MET decision making under stress. It is suggested that the corresponding habits embedded within this model could be imparted to MET members and tested by health care researchers to assess the efficacy of this integrated decision making approach in respect to enhanced team performance and patient outcomes.

Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial

AIM

Recently three large post product placement studies, comparing mechanical chest compression (cc) devices to those who received manual cc, found equivalent outcome results for both groups. Thus the question arises whether those results could be replicated using the devices on a daily routine.

METHODS

We prospectively enrolled 948 patients over a 12 months period. Chi-Square test and Mann-Whitney-U test were used to assess differences between "manual" and "mechanical" cc subgroups. Uni- and multivariate Cox regression hazard analysis were used to assess the influence of cc type on survival.

RESULTS

A mechanical cc device was used in 30.1% (n=283) cases. Patients who received mechanical cc had a significantly worse neurological outcome - measured in cerebral performance category (CPC) - than the manual cc group (56.8% vs. 78.6%, p=0.009). Patients receiving mechanical cc were significantly younger, more were male and were more likely to have bystander CPR and an initially shock-able ECG rhythm. There was no difference in the quality of CPR that might explain the worse outcome in mechanical cc patients.

CONCLUSION

Even with high quality CPR in both, manual and mechanical cc groups, outcome in patients who received mechanical cc was significantly worse. The anticipated benefits of a higher compression ratio and a steadier compression depth of a mechanical cc device remain uncertain. In this study selection for mechanical cc was not standardized, and was non-random. This merits further investigation. Further research on how mechanical cc is chosen and used should be considered.

CLINICAL TRIAL REGISTRATION

https://ekmeduniwien.at/core/catalog/2013/ (EK-Nr:1221/2013).

Debriefing in pediatrics

Debriefing is a conversational session that revolves around the sharing and examining of information after a specific event has taken place. Debriefing may follow a simulated or actual experience and provides a forum for the learners to reflect on the experience and learn from their mistakes. Originating from the military and aviation industry, it is used on a daily basis to reflect and improve the performance in other high-risk industries. Expert debriefers may facilitate the reflection by asking open-ended questions to probe into the framework of the learners and apply lessons learned to future situations. Debriefing has been proven to improve clinical outcomes such as the return of spontaneous circulation after cardiac arrest and the teaching of teamwork and communication in pediatrics. Incorporating debriefing into clinical practice would facilitate the cultural change necessary to talk more openly about team performance and learn from near misses, errors, and successes that will improve not only clinical outcome but also patient safety.

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*

OBJECTIVE

In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.

DESIGN, SETTING, AND PATIENTS

Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.

INTERVENTIONS

Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).

CONCLUSION

Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

Attitudes toward Video-Assisted Debriefing after simulation in undergraduate nursing students: an application of Q methodology

BACKGROUND

Video-Assisted Debriefing (VAD) provides an affirmative self-reflection through reviewing what went right, what went wrong, what had to be done, and what should be done in the future.

OBJECTIVE

To identify attitudes toward Video-Assisted Debriefing after a simulation in undergraduate nursing students.

DESIGN

Q-methodology, which has been identified as a method for the analysis of subjective viewpoints and to have the strengths of both qualitative and quantitative methods, was used.

SETTING

College of Nursing in Seoul.

PARTICIPANTS

A convenience P-sample consisting of 44 third-year undergraduate nursing students.

METHODS

Thirty-nine selected Q-statements from each of 44 participants (P-sample) were classified into the shape of a normal distribution using a 9-point bipolar scale from -4 for strongly disagree to +4 for strongly agree. The collected data were analyzed using the pc-QUANL program.

RESULTS

Three discrete factors emerged: Factor I (VAD helps self-reflection; strategic view), Factor II (VAD makes us tired and humiliated; reluctant view), and Factor III (VAD boosts self-confidence; forward view).

CONCLUSION

The findings could be used as a cornerstone for application of customized debriefing method to undergraduate nursing students. Debriefing techniques considering student's individual learning style.