Debriefing in the Emergency Department After Clinical Events: A Practical Guide

The utilisation of a structured debriefing framework within the pre-hospital environment: a service evaluation

Background:

Debriefing improves care and reduces error. To be effective, debriefs should be facilitated by trained individuals utilising structured and validated tools. Currently, in UK ambulance services there is no published evidence that structured processes utilising validated tools are being consistently delivered by trained facilitators, potentially impacting clinical practice.

Methods:

A pre-intervention survey related to debriefing was sent to 1000 clinicians within a specific geographical area of the trust via e-mail. In addition, 12 senior or advanced paramedics were recruited from the same area to participate in a training day and 12-week trial, utilising the Debrief Diamond as part of post-event debriefing. Following the trial period, all facilitators and participants of any recorded debriefs were invited to complete a post-intervention survey.

Results:

A total of 130 staff responded to the pre-intervention survey, with 22% reporting that previous debriefs had not identified areas for learning, and 13% reporting that previous debriefs had not identified good practice, learning opportunities or near misses. Post-intervention, 89% believed the process of debriefing was improved utilising a structured framework, 85% stated trained individuals improved the process, 93% reported the identification of good practice, 70% identified team level learning and 100% of facilitators reported improvements in identifying and supporting learning.

Conclusion:

Improvements in identifying good practice and learning opportunities were reported by both clinicians and facilitators in this evaluation, reflecting current evidence that structured and facilitated debriefs support safer care through the identification and subsequent reduction of human error. Consequently, the evaluation of appropriate debrief frameworks to provide consistency and validity to clinical debriefs in the pre-hospital environment should be considered to support safer clinical care.

Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative

BACKGROUND

The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published study detailing the utilization, process and content of hot debriefings after pediatric IHCA.

METHODS

Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments.

RESULTS

Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range [IQR] 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%).

CONCLUSION

Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.

Charge nurse facilitated clinical debriefing in the emergency department

This paper describes the development and implementation of the INFO (immediate, not for personal assessment, fast facilitated feedback, and opportunity to ask questions) clinical debriefing process. INFO enabled charge nurses to facilitate a group debriefing after critical events across three adult emergency departments (EDs) in Calgary, Alberta. Prior to implementation at our institutions, ED critical event debriefing was a highly variable event. Post-implementation, INFO critical event debriefings have become part of our ED culture, take place regularly in our EDs (254 documented debriefings between March 2016 and September 2017), with recommendations arising from these debriefings being introduced into clinical practice. The INFO clinical debriefing process addresses two significant barriers to regular ED clinical debriefing: a lack of trained facilitators and the focus on physician-led debriefings. Our experience shows that a nurse-facilitated debriefing is feasible, can be successfully implemented in diverse EDs, and can be performed by relatively inexperienced debriefers. A structured approach means that debriefings are more likely to take place and become a routine part of improving team management of high stakes or unexpected clinical events.

Maternal Hemorrhage Quality Improvement Collaborative Lessons

PURPOSE

The purpose of this study was to describe user experience with implementation of an obstetric hemorrhage toolkit and determine the degree of implementation of recommended practices that occurred during a 31-hospital quality improvement learning collaborative.

STUDY DESIGN AND METHODS

This descriptive qualitative study included semistructured interviews with 22 implementation team leaders and review of transcripts from collaborative reporting calls recorded during the hemorrhage collaborative. Interviews included open-ended, closed, and ranking questions. Numeric responses were analyzed with descriptive statistics. Open-ended responses and call transcripts were analyzed thematically.

RESULTS

Each of the 10 core toolkit components was ranked as currently "implemented" or "implemented and sustained" by at least 77% of interviewees. Most core elements were deemed "critical to retain." Respondents found debriefing the most difficult element of the toolkit to implement and sustain. Organizational context was the overarching theme regarding factors facilitating or constraining implementation. This included organizational structure and culture, previous experience with quality improvement, resources, and clinician engagement. Nurses were deeply involved in implementation and "physician buy-in" was a frequently mentioned facilitator when present and barrier when absent.

CLINICAL IMPLICATIONS

Greater understanding of and attention to organizational context and resources, greater appreciation for nursing involvement, and increased recognition of the role of organizational leadership are needed to facilitate widespread improvement initiatives in maternity care. Implementation science approaches may be useful in achieving national goals for maternal quality improvement and safety.

Educator Toolkits on Second Victim Syndrome, Mindfulness and Meditation, and Positive Psychology: The 2017 Resident Wellness Consensus Summit

Introduction

Burnout, depression, and suicidality among residents of all specialties have become a critical focus of attention for the medical education community.

Methods

As part of the 2017 Resident Wellness Consensus Summit in Las Vegas, Nevada, resident participants from 31 programs collaborated in the Educator Toolkit workgroup. Over a seven-month period leading up to the summit, this workgroup convened virtually in the Wellness Think Tank, an online resident community, to perform a literature review and draft curricular plans on three core wellness topics. These topics were second victim syndrome, mindfulness and meditation, and positive psychology. At the live summit event, the workgroup expanded to include residents outside the Wellness Think Tank to obtain a broader consensus of the evidence-based toolkits for these three topics.

Results

Three educator toolkits were developed. The second victim syndrome toolkit has four modules, each with a pre-reading material and a leader (educator) guide. In the mindfulness and meditation toolkit, there are three modules with a leader guide in addition to a longitudinal, guided meditation plan. The positive psychology toolkit has two modules, each with a leader guide and a PowerPoint slide set. These toolkits provide educators the necessary resources, reading materials, and lesson plans to implement didactic sessions in their residency curriculum.

Conclusion

Residents from across the world collaborated and convened to reach a consensus on high-yield—and potentially high-impact—lesson plans that programs can use to promote and improve resident wellness. These lesson plans may stand alone or be incorporated into a larger wellness curriculum.

The Human Factor: Optimizing Trauma Team Performance in Dynamic Clinical Environments

Resilience is built, not born, and there is no single strategy that reliably manufactures resilient performance in all circumstances. Optimizing team performance in dynamic environments involves the complex interplay of strategies that target individual preparation, team interaction, environmental optimization, and systems-level resilience engineering. To accomplish this, health care can draw influence from human factors research to inform tangible, practical, and measurable improvements in performance and outcomes, modified to suit local and domain-specific needs.

Promoting Learning and Patient Care Through Shared Reflection: A Conceptual Framework for Team Reflexivity in Health Care

Health care teams are groups of highly skilled experts who may often form inexpert teams because of a lack of collective competence. Because teamwork and collaboration form the foundation of effective clinical practice, factors that promote collective competence demand exploration. The authors review team reflexivity (TR), a concept from the psychology and management literatures, and how it could contribute to the collective competence of health care teams. TR captures a team's ability to reflect collectively on group objectives, strategies, goals, processes, and outcomes of past, current, and future performance to process key information and adapt accordingly. As an overarching process that promotes team functioning, TR builds shared mental models as well as triggering team adaptation and learning.The authors present a conceptual framework for TR in health care, describing three phases in which TR may occur: pre-action TR (briefing before patient care), in-action TR (deliberations during active patient care), and post-action TR (debriefing after patient care). Depending on the phase, TR targets either goals, taskwork, teamwork, or resources and leads to different outcomes (e.g., optimal preparation, a shared mental model, adaptation, or learning). This novel conceptual framework incorporates various constructs related to reflection and unites them under the umbrella of TR. Viewing reflection through a team lens may guide future research about team functioning, optimize training efforts, and elucidate mechanisms for workplace learning, with better patient care as the ultimate goal.

Causes for Pauses During Simulated Pediatric Cardiac Arrest

OBJECTIVES

Pauses in cardiopulmonary resuscitation negatively impact clinical outcomes; however, little is known about the contributing factors. The objective of this study is to determine the frequency, duration, and causes for pauses during cardiac arrest.

DESIGN

This is a secondary analysis of video data collected from a prospective multicenter trial. Twenty-six simulated pediatric cardiac arrest scenarios each lasting 12 minutes in duration were analyzed by two independent reviewers to document events surrounding each pause in chest compressions.

SETTING

Ten children's hospitals across Canada, the United, and the United Kingdom.

SUBJECTS

Resuscitation teams composed of three healthcare providers trained in cardiopulmonary resuscitation.

INTERVENTIONS

A simulated pediatric cardiac arrest case in a 5 year old.

MEASUREMENTS AND MAIN RESULTS

The frequency, duration, and associated factors for each pause were recorded. Communication was rated using a four-point scale reflecting the team's shared mental model. Two hundred fifty-six pauses were reviewed with a median of 10 pauses per scenario (interquartile range, 7-12). Median pause duration was 5 seconds (interquartile range, 2-9 s), with 91% chest compression fraction per scenario (interquartile range, 88-94%). Only one task occurred during most pauses (66%). The most common tasks were a change of chest compressors (25%), performing pulse check (24%), and performing rhythm check (15%). Forty-nine (19%) of the pauses lasted greater than 10 seconds and were associated with shock delivery (p < 0.001), performing rhythm check (p < 0.001), and performing pulse check (p < 0.001). When a shared mental model was rated high, pauses were significantly shorter (mean difference, 4.2 s; 95% CI, 1.6-6.8 s; p = 0.002).

CONCLUSIONS

Pauses in cardiopulmonary resuscitation occurred frequently during simulated pediatric cardiac arrest, with variable duration and underlying causes. A large percentage of pauses were greater than 10 seconds and occurred more frequently than the recommended 2-minute interval. Future efforts should focus on improving team coordination to minimize pause frequency and duration.

Pediatric Critical Event Debriefing in Emergency Medicine Training: An Opportunity for Educational Improvement

INTRODUCTION

In the emergency department (ED), critical events, including death and severe illness, are not uncommon. Critical events involving children, while less frequent, may be especially distressing. Debriefing following a critical event may serve several purposes: review of team performance, education, identification of errors, emotional support, and planning for future events. Debriefing skills and habits learned during training may be carried forward throughout an emergency physician's career. This study evaluates how educators in emergency medicine (EM) view debriefing after pediatric critical events and identifies barriers to use of debriefing in postgraduate training programs.

METHODS

In this cross-sectional observational study, we surveyed program directors (PDs) from EM residency and pediatric emergency medicine (PEM) fellowship programs via e-mail listserv. A panel of PEM experts and survey methodologists designed the survey, which was reviewed for content validity by an independent panel of EM educators. We obtained data on current debriefing practices following pediatric critical events, PDs' perceptions of ideal debriefing practices, and barriers to implementation. Data were analyzed using descriptive statistics.

RESULTS

A total of 109 PDs completed the survey (45% overall response rate). All respondents feel that debriefing pediatric critical events is useful. The majority of debriefings are initiated and led by emergency physicians as informal meetings shortly following a critical event. Debriefings are most commonly held following a patient death, although PDs feel that debriefings should also occur for other specific patient scenarios (e.g., child abuse). Barriers to debriefing include timing, scheduling, location, discomfort with debriefing, participant buy-in, and leader buy-in.

CONCLUSIONS

Program leaders in both EM and PEM believe that debriefing after pediatric critical events is important for training. Barriers to debriefing specific to the ED setting should be explored to optimize the implementation of this practice.

Accuracy of Postresuscitation Team Debriefings in a Pediatric Emergency Department

STUDY OBJECTIVE

Guideline committees recommend postresuscitation debriefings to improve performance. "Hot" postresuscitation debriefings occur immediately after the event and rely on team recall. We assessed the ability of resuscitation teams to recall their performance in team-based, hot debriefings in a pediatric emergency department (ED), using video review as the criterion standard. We hypothesized that debriefing accuracy will improve during the course of the study.

METHODS

Resuscitation physician and nurse leaders cofacilitated debriefings after ED resuscitations involving cardiopulmonary resuscitation (CPR) or intubation. Debriefing teams recorded their self-assessments of clinical performance measures with standardized debriefing forms. The debriefing form data were compared with actual performance measured by video review at 2 pediatric EDs over 22 months. CPR performance measures included time to automated external defibrillator pad placement, epinephrine administration timing, and compression pause timing. Intubation measures included occurrences of oxygen desaturation, number of intubation attempts, and use of end-tidal carbon dioxide monitoring.

RESULTS

We analyzed 100 resuscitations (14 cardiac arrests, 22 cardiac arrests with intubation, and 64 intubations). The accuracy of debriefing answers was 87%, increasing from 83% to 91% between the first and second halves of the study period (7.7% difference; 95% confidence interval 0.2% to 15%). Debriefings that acknowledged an error in certain performance measures (ie, automated external defibrillator pad placement delay, multiple intubation attempts, and occurrence of oxygen desaturation) had significantly worse performance in those specific measures on video review.

CONCLUSION

Teams in postresuscitation debriefings had a higher degree of debriefing answer accuracy in the final 50 debriefings than in the first 50. Teams also distinguished various degrees of resuscitation performance.

Post-event debriefings during neonatal care: why are we not doing them, and how can we start?

Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren't they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

The use of high-fidelity manikins for advanced life support training--A systematic review and meta-analysis

OBJECTIVES

The objective of this study was to evaluate the effectiveness of high versus low fidelity manikins in the context of advanced life support training for improving knowledge, skill performance at course conclusion, skill performance between course conclusion and one year, skill performance at one year, skill performance in actual resuscitations, and patient outcomes.

METHODS

A systematic search of Pubmed, Embase and Cochrane databases was conducted through January 31, 2014. We included two-group non-randomized and randomized studies in any language comparing high versus low fidelity manikins for advanced life support training. Reviewers worked in duplicate to extract data on learners, study design, and outcomes. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the overall quality of evidence for each outcome.

RESULTS

3840 papers were identified from the literature search of which 14 were included (13 randomized controlled trials; 1 non-randomized controlled trial). Meta-analysis of studies reporting skill performance at course conclusion demonstrated a moderate benefit for high fidelity manikins when compared with low fidelity manikins [Standardized Mean Difference 0.59; 95% CI 0.13-1.05]. Studies measuring skill performance at one year, skill performance between course conclusion and one year, and knowledge demonstrated no significant benefit for high fidelity manikins.

CONCLUSION

The use of high fidelity manikins for advanced life support training is associated with moderate benefits for improving skills performance at course conclusion. Future research should define the optimal means of tailoring fidelity to enhance short and long term educational goals and clinical outcomes.