Implementation of an Innovative, Multiunit, Postevent Debriefing Program in a Children's Hospital

What and when to debrief: a scoping review examining interprofessional clinical debriefing

INTRODUCTION

Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.

METHODS

Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.

RESULTS

Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.

CONCLUSIONS

The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.

Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital

INTRODUCTION

An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years.

METHODS

A multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes.

RESULTS

Post-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %).

DISCUSSION

Clinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.

Mitigating Moral Distress: Pediatric Critical Care Nurses' Recommendations

In pediatric critical care, nurses are the primary caregivers for critically ill children and are particularly vulnerable to moral distress. There is limited evidence on what approaches are effective to minimize moral distress among these nurses. To identify intervention attributes that critical care nurses with moral distress histories deem important to develop a moral distress intervention. We used a qualitative description approach. Participants were recruited using purposive sampling between October 2020 to May 2021 from pediatric critical care units in a western Canadian province. We conducted individual semi-structured interviews via Zoom. A total of 10 registered nurses participated in the study. Four main themes were identified: (1) "I'm sorry, there's nothing else": increasing supports for patients and families; (2) "someone will commit suicide": improving supports for nurses: (3) "Everyone needs to be heard": improving patient care communication; and (4) "I didn't see it coming": providing education to mitigate moral distress. Most participants stated they wanted an intervention to improve communication among the healthcare team and noted changes to unit practices that could decrease moral distress. This is the first study that asks nurses what is needed to minimize their moral distress. Although there are multiple strategies in place to help nurses with difficult aspects of their work, additional strategies are needed to help nurses experiencing moral distress. Moving the research focus from identifying moral distress towards developing effective interventions is needed. Identifying what nurses need is critical to develop effective moral distress interventions.

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats

BACKGROUND

Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location.

METHODS

Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medication, resource/system, or technical skill categories. A hazard matrix was used by multiplying occurrence frequency of LST in simulation and real clinical events (based on expert opinion) and severity of the LST based on agreement between two evaluators.

RESULTS

Seventy-four in situ cardiac arrest simulations were conducted hospital wide. Hundreds of safety threats were identified, analyzed, and categorized yielding 106 unique latent safety threats: 21 in the equipment category, 8 in the medication category, 41 in the resource/system category, and 36 in the technical skill category. The team worked to mitigate all LSTs with priority mitigation to imminent risk level threats, then high risk threats, followed by non-imminent risk LSTs. Four LSTs were deemed imminent, requiring immediate remediation post debriefing. Fifteen LSTs had a hazard ratio greater than 8 which were deemed high risk for remediation. Depending on the category of threat, a combination of mitigating steps including the immediate fixing of an identified problem, leadership escalation, and programmatic intervention recommendations occurred resulting in mitigation of all identified threats.

CONCLUSIONS

Hospital-wide in situ cardiac arrest team simulation offers an effective way to both identify and mitigate LSTs. Safety during cardiac arrest care is improved through the use of a system in which LSTs are escalated urgently, mitigated, and conveyed back to participants to provide closed loop debriefing. Lastly, this hospital-wide, multidisciplinary initiative additionally served as an educational needs assessment allowing for informed, iterative education and systems improvement initiatives targeted to areas of LSTs and areas of opportunity.

From the Frontlines: A Qualitative Study of Staff Experiences With Clinical Event Debriefing

OBJECTIVES

Clinical event debriefing (CED) can improve patient care and outcomes, but little is known about CED across inpatient settings, and participant experiences have not been well described. In this qualitative study, we sought to characterize and compare staff experiences with CED in 2 hospital units, with a goal of generating recommendations for a hospital-wide debriefing program.

METHODS

We conducted 32 semistructured interviews with clinical staff who attended a CED in the previous week. We explored experiences with CED, with a focus on barriers and facilitators. We used content analysis with constant comparative coding to understand priorities identified by participants. We used inductive reasoning to develop a set of CED practice recommendations to match participant priorities.

RESULTS

Three primary themes emerged related to CED barriers and facilitators. (1) Factors affecting attendance: most respondents voiced a need for frontline staff inclusion in CED, but they also cited competing clinical duties and scheduling conflicts as barriers. (2) Factors affecting participant engagement: respondents described factors that influence participant engagement in reflective discussion. They described that the CED leader must cultivate a psychologically safe environment in which participants feel empowered to speak up, free from judgment. (3) Factors affecting learning and systems improvement: respondents emphasized that the CED group should generate a plan for improvement with accountable stakeholders. Collectively, these priorities propose several recommendations for CED practice, including frontline staff inclusion.

CONCLUSIONS

In this study, we propose recommendations for CED that are derived from first-hand participant experiences. Future study will explore implementation of CED practice recommendations.

Evolution of clinical event debriefs in a quaternary pediatric emergency department after implementation of a debriefing tool

BACKGROUND

Debriefing clinical events in the emergency department (ED) can enhance team performance and provide mutual support. However, ED debriefing remains infrequent and nonstandardized. A clinical tool (DISCERN-Debriefing In Situ Conversation after Emergent Resuscitation Now) was developed to facilitate ED debriefing. To date, there are no studies providing qualitative analysis of clinical event debriefs done using such a tool. Our goal was to explore common themes elicited by debriefing following implementation of DISCERN.

METHODS

This was a retrospective mixed-methods study analyzing DISCERN data from 2012 through 2017 in a pediatric ED. Quantitative data were analyzed using descriptive statistics. With constant comparison analysis, themes were categorized when applicable within the context of crisis resource management (CRM) principles, previously used as a framework for description of nontechnical skills. Member checking was performed to ensure trustworthiness.

RESULTS

We reviewed 400 DISCERN forms. Overall, 170 (41.6%) of target clinical events were debriefed during the study period. The number of clinical events debriefed per year decreased significantly over the study period, from 118 debriefed events in 2013 to 20 debriefed events in 2017 (p < 0.001). Events were more likely to be debriefed if cardiopulmonary resuscitation was needed (odds ratio [OR] = 11.8, 95% confidence interval [CI] = 4.1-33.8]) or if the patient expired (OR = 8.9, 95% CI = 2.7-29.1]). CRM principles accounted for 81% of debriefing statements, focusing on teamwork, communication, and preparation, and these themes remained consistent throughout the study period.

CONCLUSIONS

Use of the DISCERN tool declined over the study period. The DISCERN tool was utilized more commonly after the highest-acuity events. Clinical event debriefs aligned with CRM principles, with medical knowledge discussed less frequently, and the content of debriefs remained stable over time.

Debrief it all: a tool for inclusion of Safety-II

Safety science in healthcare has historically focused primarily on reducing risk and minimizing harm by learning everything possible from when things go wrong (Safety-I). Safety-II encourages the study of all events, including the routine and mundane, not only bad outcomes. While debriefing and learning from positive events is not uncommon or new to simulation, many common debriefing strategies are more focused on Safety-I. The lack of inclusion of Safety-II misses out on the powerful analysis of everyday work.

A debriefing tool highlighting Safety-II concepts was developed through expert consensus and piloting and is offered as a guide to encourage and facilitate inclusion of Safety-II analysis into debriefings. It allows for debriefing expansion from the focus on error analysis and “what went wrong” or “could have gone better” to now also capture valuable discussion of high yield Safety-II concepts such as capacities, adjustments, variation, and adaptation for successful operations in a complex system. Additionally, debriefing inclusive of Safety-II fosters increased debriefing overall by encouraging debriefing when “things go right”, not historically what is most commonly debriefed.

Development and implementation of an end-of-shift clinical debriefing method for emergency departments during COVID-19

BACKGROUND

Multiple guidelines recommend debriefing after clinical events in the emergency department (ED) to improve performance, but their implementation has been limited. We aimed to start a clinical debriefing program to identify opportunities to address teamwork and patient safety during the COVID-19 pandemic.

METHODS

We reviewed existing literature on best-practice guidelines to answer key clinical debriefing program design questions. An end-of-shift huddle format for the debriefs allowed multiple cases of suspected or confirmed COVID-19 illness to be discussed in the same session, promoting situational awareness and team learning. A novel ED-based clinical debriefing tool was implemented and titled Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE). A facilitator experienced in simulation debriefings would facilitate a short (10-25 min) discussion of the relevant cases by following a scripted series of stages for debriefing. Data on the number of debriefing opportunities, frequency of utilization of debriefing, debriefing location, and professional background of the facilitator were analyzed.

RESULTS

During the study period, the ED treated 3386 suspected or confirmed COVID-19 cases, with 11 deaths and 77 ICU admissions. Of the 187 debriefing opportunities in the first 8-week period, 163 (87.2%) were performed. Of the 24 debriefings not performed, 21 (87.5%) of these were during the four first weeks (21/24; 87.5%). Clinical debriefings had a median duration of 10 min (IQR 7-13). They were mostly facilitated by a nurse (85.9%) and mainly performed remotely (89.8%).

CONCLUSION

Debriefing with DISCOVER-PHASE during the COVID-19 pandemic were performed often, were relatively brief, and were most often led remotely by a nurse facilitator. Future research should describe the clinical and organizational impact of this DISCOVER-PHASE.