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Implementation of an In Situ Qualitative Debriefing Tool for Resuscitations
Abstract
Aim:
Multiple guidelines recommend debriefing of resuscitations to improve clinical performance. We implemented a novel standardized debriefing program using a Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) tool.
Methods:
Following the development of the evidence-based DISCERN tool, we conducted an observational study of all resuscitations (intubation, CPR, and/or defibrillation) at a pediatric emergency department (ED) over one year. Resuscitation interventions, patient survival, and physician team leader characteristics were analyzed as predictors for debriefing. Each debriefing's participants, time duration, and content were recorded. Thematic content of debriefings was categorized by framework approach into Team Emergency Assessment Measure (TEAM) elements.
Results:
There were 241 resuscitations and 63 (26%) debriefings. A higher proportion of debriefings occurred after CPR (p<0.001) or ED death (p<0.001). Debriefing participants always included an attending and nurse; the median number of staff roles present was six. Median intervals (from resuscitation end to start of debriefing) & debriefing durations were 33 (IQR 15, 67) and 10 min (IQR 5, 12), respectively. Common TEAM themes included co-operation/coordination (30%), communication (22%), and situational awareness (15%). Stated reasons for not debriefing included: unnecessary (78%), time constraints (19%), or other reasons (3%).
Conclusions:
Debriefings with the DISCERN tool usually involved higher acuity resuscitations, involved most of the indicated personnel, and lasted less than 10 min. Future studies are needed to evaluate the tool for adaptation to other settings and potential impacts on education, quality improvement programming, and staff emotional well-being.
... Eight tools originated from the USA, [19][20][21][22][23][24][25][26] five from the UK, 27-31 four from Australia 32-35 and one from each of Ireland, 36 Canada 37 and Italy. 38 One was multinational. ...
... Twelve tools detailed where the debrief should take place: a private/quiet/isolated environment (Self-reflection module, TALK, DISCERN, AIR and DISCOVER-TooL), 23 25 28 35 38 an area physically distant from the clinical event (NICU debrief protocol and TAKE STOCK), 27 30 inside the resuscitation room (Emergency airway management and STOP5), 31 32 non-clinical work rooms (PICU cardiac arrest debriefing tool and Neonatal unit debriefing tool) 22 34 or 'anywhere' (Postevent debriefing study tool). 33 In most cases, recommended timing was immediately after the clinical event, in keeping with the concept of a 'hot' debrief. ...
... 24 28 Voluntary participation was emphasised by seven tools: Emergency airway management, Postevent debriefing study tool, Cardiac arrests in emergency department, DISCERN, AIR, STOP5 and DISCOVER-TooL. 23 25 31-33 35 36 Education All tools identified areas for enhancing performance. The 'plus/delta' method was the most commonly used structure for achieving this, which was used by Emergency airway management, Postevent debriefing study tool, Self-reflection module, PEARLS approach to CD, Cardiac arrests in emergency department, Neonatal unit debriefing tool, DISCERN, AIR, INFO, TAKE STOCK, Hot debrief tool, TeamSTEPPS, STOP5 and Discover-TooL. ...
Background and objectives
Clinical debriefing (CD) following a clinical event has been found to confer benefits for staff and has potential to improve patient outcomes. Use of a structured tool to facilitate CD may provide a more standardised approach and help overcome barriers to CD; however, we presently know little about the tools available. This systematic review aimed to identify tools for CD in order to explore their attributes and evidence for use.
Methods
A systematic review was conducted in line with PRISMA standards. Five databases were searched. Data were extracted using an electronic form and analysed using critical qualitative synthesis. This was guided by two frameworks: the ‘5 Es’ (defining attributes of CD: educated/experienced facilitator, environment, education, evaluation and emotions) and the modified Kirkpatrick’s levels. Tool utility was determined by a scoring system based on these frameworks.
Results
Twenty-one studies were included in the systematic review. All the tools were designed for use in an acute care setting. Criteria for debriefing were related to major or adverse clinical events or on staff request. Most tools contained guidance on facilitator role, physical environment and made suggestions relating to psychological safety. All tools addressed points for education and evaluation, although few described a process for implementing change. Staff emotions were variably addressed. Many tools reported evidence for use; however, this was generally low-level, with only one tool demonstrating improved patient outcomes.
Conclusion
Recommendations for practice based on the findings are made. Future research should aim to further examine outcomes evidence of these tools in order to optimise the potential of CD tools for individuals, teams, healthcare systems and patients.
... Most prior reports of clinical event debriefings have focused on resuscitation events [17][18][19][20]. To help teams debrief issues related to the COVID-19 pandemic, a workgroup of healthcare providers at a quaternary children's and women's hospital created a debriefing tool called the Debriefing In Suspected COVid-19 to Encourage Reflection and Team Learning (DISCOVER-TooL) [21]. ...
... To help teams debrief issues related to the COVID-19 pandemic, a workgroup of healthcare providers at a quaternary children's and women's hospital created a debriefing tool called the Debriefing In Suspected COVid-19 to Encourage Reflection and Team Learning (DISCOVER-TooL) [21]. This novel tool was a modification of the Debriefing In-Situ Conversion after Emergent Resuscitation Now (DISCERN) tool, initially developed for "hot debriefing" (i.e., short team conversations within minutes to hours of a clinical event) in the pediatric emergency department (ED) at our hospital [18]. The aim of the DISCOVER-TooL was to help teams rapidly learn what was working well and identify opportunities for improvement that could be addressed in real time or incorporated into future process changes. ...
... We used constant comparative coding with an integrated deductive and inductive approach [25]. We initially developed a codebook based on themes from the Team Emergency Assessment Measure framework [18,[25][26][27]. Two investigators (PCM, TBW) reviewed all quoted units while two investigators (CBD, ZM) coded a random subset. ...
Background:
Healthcare workers faced unique challenges during the early months of the COVID-19 pandemic which necessitated rapid adaptation. Clinical event debriefings (CEDs) are one tool that teams can use to reflect after events and identify opportunities for improving their performance and their processes. There are few reports of how teams have used CEDs in the COVID-19 pandemic. Our aim is to explore the issues discussed during COVID-19 CEDs and propose a framework model for qualitatively analyzing CEDs.
Methods:
This was a descriptive, qualitative study of a hospital-wide CED program at a quaternary children's hospital between March and July 2020. CEDs were in-person, team-led, voluntary, scripted sessions using the Debriefing in Suspected COVID-19 to Encourage Reflection and Team Learning (DISCOVER-TooL). Debriefing content was qualitatively analyzed using constant comparative coding with an integrated deductive and inductive approach. A novel conceptual framework was proposed for understanding how debriefing content can be employed at various levels in a health system for learning and improvement.
Results:
Thirty-one debriefings were performed and analyzed. Debriefings had a median of 7 debriefing participants, lasted a median of 10 min, and were associated with multiple systems-based process improvements. Fourteen themes and 25 subthemes were identified and categorized into a novel Input-Mediator-Output-Input Debriefing (IMOID) model. The most common themes included communication, coordination, situational awareness, team member roles, and clinical standards.
Conclusions:
Teams identified diverse issues in their debriefing discussions related to areas of high performance and opportunities for improvement in their care of COVID-19 patients. This model may help healthcare systems to understand how CED tools can be used to accelerate organizational learning to promote safety and improve outcomes in changing clinical environments.
... 4,9 A previous study performed at our institution detailed the imple- initial study reported on the debriefing of resuscitation events defined as provision of cardiopulmonary resuscitation (CPR), defibrillation, endotracheal intubation, or high-acuity trauma in the ED. 13 Cumulative DISCERN tool data have not been reported since that time, although many subsequent clinical event debriefs have since occurred. ...
... Quantitative and descriptive information from each event debriefed was documented on the DISCERN form, 13 including team leader (attending or trainee), year, type of event (CPR, intubation, etc.), time to start and duration of debrief, patient outcome, debrief leader, and team members present. ...
... 2,4,7,[9][10][11][12]18 In response to such needs, the DISCERN tool provides a structured format to facilitate debriefs in the ED led by members of the clinical team. 13 We found that after its implementation, instances of clinical event debriefing were initially common, but then decreased in subsequent years. Using a mixed-methods approach, we ascertained which clinical themes were most widely discussed and found that nontechnical aspects of resuscitations were mentioned most frequently. ...
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.
... 7 Debriefings have been used by HROs such as aviation 8 and the military 9,10 to learn from events to mitigate future risk. Clinical event debriefing (CED) provides opportunities for teams to review a clinical event, [11][12][13][14] reflect on performance, [11][12][13][14][15] identify safety concerns, [11][12][13][14] and develop performance improvement strategies. 11,12,14 Debriefing has been associated with a 20% to 25% improvement in individual and team performance. ...
... Despite the stated benefits of CEDs, most team members of clinical settings do not debrief frequently. 10,14,15,18 Approximately 50% of surveyed pediatric emergency nurses and physicians estimated that debriefing after resuscitations occurred less than 25% of the time. 14 One of the main barriers to consistent debriefing is the lack of debriefing guidelines and tools. ...
... 14 One of the main barriers to consistent debriefing is the lack of debriefing guidelines and tools. 12,14,15,[18][19][20][21] The resources available to guide this essential practice include an acronym framework, 22 an ED postresuscitation debriefing tool, 15 and debriefing scripts focused on general concepts, 18 simulation scenarios, 23 or trauma resuscitations. 13 Through the researchers' review of the literature, we found no ED-specific debriefing guidelines that have undergone a formalized validation process. ...
Objective:
Clinical event debriefing is recommended by the American Heart Association and the European Resuscitation Council, because debriefings improve team performance. The purpose here was to develop and validate tools needed to overcome barriers to debriefing in the emergency department.
Method:
This quality improvement project was conducted in 4 phases. Phase 1: Current evidence related to debriefing in the emergency department was reviewed and synthesized to inform an iterative process for drafting the debriefing guideline and instrument for documentation. Phase 2: Content Validity Index of the tools was evaluated by obtaining ratings of items' clarity and relevance from 5 national experts in 2 rounds of review. On the basis of experts' feedback, tools were revised, and a Facilitators' Guide was created. Phase 3: The validated debriefing tools were implemented. Phase 4: Debriefing facilitators completed a survey about their experience with using the new tools.
Results:
The Content Validity Index of 71 debriefing tool items (guideline, instrument, Facilitators' Guide) was 0.93 and 0.96 for clarity and relevance, respectively. Of the 32 debriefings conducted during the first 8 weeks of implementation, 53% described patient safety concerns, and 97% described recommendations to improve performance. Most (94%) facilitators agreed that the guideline clarified debriefing requirements.
Conclusion:
The use of debriefing tools validated by computation of the Content Validity Index led to the identification of safety threats and recommendations to improve care processes. These tools can be used in ED settings to promote team learning and aid in identifying and resolving safety concerns.
... Many debriefing methods demand considerable skill, which impedes effective implementation. The plus-delta approach to debriefing has multiple benefits since it is conceptually simple and easy to implement, while promoting learner capacity for selfassessment-a skill vital for safe clinical practice [2,5,[7][8][9][10][11][12]. With plus-delta, facilitators engage learners in a self-assessment of their own performance [12], which in turn provides opportunity for individual and team reflexivity [13,14]. ...
... When applying this approach, facilitators ask learners: "What went well and what would you do differently (or improve) next time?" [7,9,12]; "What did you do well, and what did not go well, and why?" [10]; "What was easy and what was challenging for you?" [5]; or other similar questions. Outside of healthcare, the US Army has adopted a version of this approach through a performance feedback method termed "After Action Review" [16,17]. ...
... Following training, soldiers engage in a facilitated conversation to clarify what aspects of performance met pre-defined standards, and where there was opportunity for improvement [17]. The plus-delta approach, when coupled with feedback and teaching, can be used as the primary conversational strategy in a debriefing [7,[9][10][11] or used more selectively by blending it with other strategies (e.g., focused facilitation) depending on the learning context, amount of time available, and facilitator preferences (e.g., learner vs. instructor-centered debriefing) [12,18]. Ideally, an effective plus-delta generates two lists of behaviors (i.e., things that the learners felt went well, and things that the learners felt could be improved), which then prompts further discussion, reflection, and/or learning during the debriefing. ...
The healthcare simulation field has no shortage of debriefing options. Some demand considerable skill which serves as a barrier to more widespread implementation. The plus-delta approach to debriefing offers the advantages of conceptual simplicity and ease of implementation. Importantly, plus-delta promotes learners’ capacity for a self-assessment, a skill vital for safe clinical practice and yet a notorious deficiency in professional practice. The plus-delta approach confers the benefits of promoting uptake of debriefing in time-limited settings by educators with both fundamental but also advanced skills, and enhancing essential capacity for critical self-assessment informed by objective performance feedback. In this paper, we describe the role of plus-delta in debriefing, provide guidance for incorporating informed learner self-assessment into debriefings, and highlight four opportunities for improving the art of the plus delta: (a) exploring the big picture vs. specific performance issues, (b) choosing between single vs. double-barreled questions, (c) unpacking positive performance, and (d) managing perception mismatches.
... Though this begs the questions: what constitutes a "good" debriefing, how does an individual debriefer achieve this, and how can it be scaled across an organization? While there are faculty development programs available [16,17], there is no national standard for faculty training in medical simulation or debriefing, despite ample literature supporting specific debriefing best practices [8][9][10][11][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]. ...
... PEARLS scripting improves model accessibility for those debriefers still developing their debriefing skills [18]. PEARLS circumvents some limitations of other debriefing models, including the prioritization of expediency and a requirement for high levels of experience for successful application [20,[23][24][25]. The PEARLS model presents a sequence of four stages: (1) reactions, (2) description, (3) analysis, and (4) summary [18]. ...
... These stages and their associated sample phrases assist debriefers in setting the stage for the debriefing, organizing the debriefing, and helping debriefers pose questions [18]. The PEARLS approach combines the debriefing strategies of learner self-assessment [20,24,26], facilitated reflection and understanding [27][28][29], directed performance feedback [30,31], and focused teaching [28,32]. PEARLS contains these blended strategies within a consolidated model [18]. ...
Purpose
Debriefing is necessary for effective simulation education. The PEARLS (Promoting Excellence and Reflective Learning in Simulations) is a scripted debriefing model that incorporates debriefing best practices. It was hypothesized that student simulation performance might impact facilitator adherence to the PEARLS debriefing model. There are no published findings on the effect of student performance on debriefer behavior.
Methods
Third-year medical students participated in a video-recorded, formative simulation to treat a high-fidelity mannequin for an asthma exacerbation. A faculty debriefer trained in the PEARLS model evaluated student performance with a standardized rubric and conducted a recorded debriefing. Debriefing recordings were analyzed for debriefer adherence to the PEARLS model. Debriefers were assigned a debriefing score (DS) from 0 to 13; 13 was perfect adherence to the model. Definitive intervention (DI) for asthma exacerbation was defined as bronchodilator therapy. Critical actions were as follows: a focused history, heart/lung exam, giving oxygen, and giving a bronchodilator.
Results
Mean DS for the debriefers of students who provided DI was 8.57; 9.14 for those students who did not ( P = 0.25). Mean DS for debriefers of students who completed all critical actions was 8.68; 8.52 for those students who did not ( P = 0.62). Analysis of elapsed time to DI showed no relationship between the time DI was provided and DS.
Conclusions
Student performance had no impact on debriefer performance, suggesting the PEARLS model is an effective aid for debriefers, regardless of learner performance. These findings suggest student performance may not bias facilitators’ ability to conduct quality debriefings.
... Simulation-based CPR training methods allow learners to practice in a realistic scenario, measure CPR parameters and, thus, have been shown to improve resuscitation performance [16,17]. Similarly, the use of debriefng has been considered as an efective tool in improving resuscitation quality [8,18]. An open discussion model during debriefng has shown to be a simple and efective tool in addressing key aspects of the actions taken during cardiac arrest events and gives an opportunity for providers to efciently adapt and improve the team's performance [18]. ...
... Similarly, the use of debriefng has been considered as an efective tool in improving resuscitation quality [8,18]. An open discussion model during debriefng has shown to be a simple and efective tool in addressing key aspects of the actions taken during cardiac arrest events and gives an opportunity for providers to efciently adapt and improve the team's performance [18]. One study in adult patients compared the efects of debriefng intervention between baseline and intervention periods and found that Critical Care Research and Practice debriefng methods improved the rates of ROSC [19]. ...
Introduction:
Various quality improvement (QI) interventions have been individually assessed for the quality of cardiopulmonary resuscitation (CPR). We aimed to assess the QI bundle (hands-on training and debriefing) for the quality of CPR in our children's hospital. We hypothesized that the QI bundle improves the quality of CPR in hospitalized children.
Methods:
We initiated a QI bundle (hands-on training and debriefing) in August 2017. We conducted a before-after analysis comparing the CPR quality during July 2013-May 2017 (before) and January 2018-December 2020 (after). We collected data from the critical events logbook on CPR duration, chest compressions (CC) rate, ventilation rate (VR), the timing of first dose of epinephrine, blood pressure (BP), end-tidal CO2 (EtCO2), and vital signs monitoring during CPR. We performed univariate analysis and presented data as the median interquartile range (IQR) and in percentage as appropriate.
Results:
We compared data from 58 CPR events versus 41 CPR events before and after QI bundle implementation, respectively. The median (IQR) CPR duration for the pre- and post-QI bundle was 5 (1-13) minutes and 3 minutes (1.25-10), and the timing of the first dose of epinephrine was 2 (1-2) minutes and 2 minutes (1-5), respectively. We observed an improvement in compliance with the CC rate (100-120 per minute) from 72% events before versus 100% events after QI bundle implementation (p=0.0009). Similarly, there was a decrease in CC interruptions and hyperventilation rates from 100% to 50% (p=0.016) and 100% vs. 63% (p=<0.0001) events before vs. after QI bundle implementation, respectively. We also observed improvement in BP monitoring from 36% before versus 60% after QI bundle (p=0.014).
Conclusion:
Our QI bundle (hands-on training and debriefing) was associated with improved compliance with high-quality CPR in children.
... The first being DISCERN, an established, plus-delta based debriefing method. The second PRD tool we assessed was the PCP, which while still rooted in plusdelta principles has a greater focus on health care provider wellbeing and emotional support [15,16]. DIS-CERN is a more involved debriefing process that targets QI-type performance improvement, while PCP is a simpler process targeted more at the emotional well-being of care team members [13]. ...
... The process of debriefing has been shown to play an important role in identifying and addressing human factors in the healthcare setting as they pertain to patient safety [15]. It has also been shown to be recognized as an important aspect of patient care, quality improvement, and medical education by healthcare providers, but is difficult to implement into the clinical setting due to poor standardization, beliefs surrounding a certain degree of training needed to facilitate appropriate debriefings, as well as workload demands and time constraints. ...
Background
Post-resuscitation debriefing (PRD) is the process of facilitated, reflective discussion, enabling team-based interpersonal feedback and identification of systems-level barriers to patient care. The importance and benefits of PRD are well recognized; however, numerous barriers exist, preventing its practical implementation. Use of a debriefing tool can aid with facilitating debriefing, creating realistic objectives, and providing feedback.
Objectives
To assess utility of two PRD tools, Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) and Post-Code Pause (PCP), through user preference. Secondary aims included evaluating differences in quality, subject matter, and types of feedback between tools and implications on quality improvement and patient safety.
Methods
Prospective, crossover study over a 12-month period from February 2019 to January 2020. Two PDR tools were implemented in 8 week-long blocks in acute care settings at a tertiary care children’s hospital. Debriefings were triggered for any intubation, resuscitation, serious/unanticipated patient outcome, or by request for distressing situations. Post-debriefing, team members completed survey evaluations of the PDR tool used. Descriptive statistics were used to analyze survey responses. A thematic analysis was conducted to identify themes that emerged from qualitative responses.
Results
A total of 114 debriefings took place, representing 655 total survey responses, 327 (49.9%) using PCP and 328 (50.1%) using DISCERN. 65.2% of participants found that PCP provided emotional support while only 50% of respondents reported emotional support from DISCERN. PCP was found to more strongly support clinical education (61.2% vs 56.7%). There were no significant differences in ease of use, support of the debrief process, number of newly identified improvement opportunities, or comfort in making comments or raising questions during debriefs between tools. Thematic analysis revealed six key themes: communication, quality of care, team function & dynamics, resource allocation, preparation and response, and support.
Conclusion
Both tools provide teams with an opportunity to reflect on critical events. PCP provided a more organized approach to debriefing, guided the conversation to key areas, and discussed team member wellbeing. When implementing a PRD tool, environmental constraints, desired level of emotional support, and the extent to which open ended data is deemed valuable should be considered.
... Past research resulted in the development of guidance to conduct clinical debriefings (8,9,13,14). During COVID-19, the Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE) was specifically developed to implement a standardized clinical team debriefing program (15). ...
... During COVID-19, the Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE) was specifically developed to implement a standardized clinical team debriefing program (15). The DISCOVER-PHASE seeks to analyze all types of events encountered and was designed to be used at the end of shift (13). It employs a plus/delta method. ...
Background
The COVID-19 crisis has radically affected our healthcare institutions. Debriefings in clinical settings provide a time for the clinicians to reflect on the successes (pluses) and difficulties (deltas) encountered. Debriefings tend to be well-received if included in the broader management of the unit. The goal of this study was to develop a framework to categorize these debriefings and to assess its worthiness.
Methods
A qualitative approach based on a grounded theory research method was adopted resulting in the “Debriefing and Organizational Lessons Learned” (DOLL) framework. Debriefings were conducted within two Emergency Departments of a Belgian University Hospital during an 8-week period. In the first step, three researchers used debriefing transcripts to inductively develop a tentative framework. During the second step, these three researchers conducted independent categorizations of the debriefings using the developed framework. In step 3, the team analyzed the data to understand the utility of the framework. Chi-square was conducted to examine the associations between the item types (pluses and deltas) and the framework's dimensions.
Results
The DOLL is composed of seven dimensions and 13 subdimensions. Applied to 163 debriefings, the model identified 339 items, including 97 pluses and 242 deltas. Results revealed that there was an association between the frequency of pluses and deltas and the dimensions ( p < 0.001). The deltas were mainly related to the work environment (equipment and maintenance) ( p < 0.001) while the pluses identified tended to be related to the organization of the unit (communication and roles) ( p < 0.001). With leadership's support and subsequent actions, clinicians were more enthusiastic about participating and the researchers anecdotally detected a switch toward a more positive organizational learning approach.
Conclusion
The framework increases the potential value of clinical debriefings because it organizes results into actionable areas. Indeed, leadership found the DOLL to be a useful management tool. Further research is needed to investigate how DOLL may work in non-crisis circumstances and further apply the DOLL into incident reporting and risk management process of the unit.
... Hicks et al. (2018) discovered that when leaders are designated as those accountable for any actions suggested during a post-incident debrie ng session, their position can bias or impair their ability to lead post-incident debrie ngs effectively. To address this, it has been suggested that a member of the team who is less active or an external provider facilitate discussions in order to reduce bias in relation to decisions made and actions taken following the debrie ng [153,154]. Several studies have agreed that debrie ng training should highlight issues related to response. According to Shinnick et al., (2011), debrie ng is used in health care to facilitate discussion of actions and cognitive processes, to foster re ection and to result in improved practice. ...
... According to Shinnick et al., (2011), debrie ng is used in health care to facilitate discussion of actions and cognitive processes, to foster re ection and to result in improved practice. Mullan et al., (2013) recommended that debrie ng should result in future improvements in clinical performance, education, team morale and emotional processing. Gilmartin et al.,(2020)found that debrie ng was an effective tool for promoting quality improvement and improving patient care within the department, as it allowed participants to share their perspectives and contribute to continuous improvement. ...
There is a lack of knowledge regarding communication and information exchange between the emergency medical teams (EMTs) during emergencies, particularly in the Riyadh region of the Kingdom of Saudi Arabia (KSA). The aim of this study is to explore EMTs’ experiences of communication and information exchange during difficult emergency situations in the city of Riyadh.
A qualitative exploratory study was undertaken to explore the experiences of 62 respondents from the Saudi Red Crescent Authority (SRCA) and emergency departments (EDs): a total of 18 were SRCA staff (three call takers, four dispatchers, three field supervisors and eight paramedics), and a total of 44 from hospital EDs, comprising 19 ED nurse managers, 12 ED physician consultants and 13 ED paramedics. Semi-structured interviews were held with the participants, who all had the experience of responding to emergencies and had the authority to communicate with one another. The interviews were tape-recorded and transcribed verbatim and the transcripts were analysed using Braun and Clarke’s thematic analysis [1]. NVIVO 11 was used to aid data management.
Three themes were identified comprising central factors that influence coordination and communication between the participants. These themes were (1) the emotional impact on SRCA staff performance, (2) the effectiveness of the emergency response, and (3) perceptions of emergencies preparation. The first theme highlighted important factors related to emotional and well-being, which impact the performance of the SRCA operation centre staff and have an impact on the information shared with other relevant staff. In the second theme, issues that emerged that related to the effectiveness of the emergency response, coordination and communication between the EMTs were highlighted to be limited in effectiveness. Although several communication systems were used, some of them were not formally sanctioned and some were technical issues related to the systems used. The third theme explored participants’ perceptions of emergencies preparation, and again the findings demonstrated limited evidence of disaster management training or preparation particularly between EMTs. The training in communication among EMTs staff in preparing for disasters was similarly found to have deficits and could be improved. Finally, the findings from this study demonstrated that the level of debriefing that was put in place following an incident could be substantially improved.
Communication between EMTs not only involves the use of advanced technology but also requires improvements in coordinated communication within and between EMTs in relation to an effective response to emergencies and disasters. This could be achieved if the directors, managers and policymakers appreciated more fully the importance of the factors to be considered in relation to the effective use of ICT, the adverse impact of the ineffective use of communications systems, and how the coordination of services could be improved during emergency situations.
... This is often done through group reflection on the shared experience, which is known as debriefing in the clinical context. 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. ...
... 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. Debriefing was seen as a strategy that leads to rich learning opportunities, whilst recognising the unique, complex and chaotic environment in which practice occurs. ...
... This is often done through group reflection on the shared experience, which is known as debriefing in the clinical context. 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. ...
... 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. Debriefing was seen as a strategy that leads to rich learning opportunities, whilst recognising the unique, complex and chaotic environment in which practice occurs. ...
Background
Patient safety and safety culture are critical for quality healthcare delivery in general and in Emergency Departments (EDs) in particular. The aim of this study is to identify strategies that may contribute to the improvement and maintenance of patient safety culture and which are considered most feasible in the ED environment.
Methods
A two-step modified Delphi method with 11 experts' panel was performed to establish consensus. A list of potential expert participants with a background in patient safety culture in EDs was compiled through the professional networks of the supervisory team. Snowball sampling was used to identify additional possible participants. The expert panel included key leaders in the emergency medicine community in Queensland, Australia: patient safety experts and researchers, patient safety directors, and healthcare providers in an Australian ED The study ran from September 2018 to December 2018. The tool used in Round 1 in this study was developed through triangulating the outcomes of a review of literature, results from a survey of ED staff and findings from semi-structured interviews with key stakeholders in ED. The results from Round 1 informed the development of the Round 2 tool. The responses from the Delphi Round 1 tool were analysed as both qualitative data and quantitative data. The responses from the Delphi Round 2 tool were treated as quantitative data and analysed with the SPSS software. Consensus was calculated based on more than 80% agreement in collapsed categories 1 and 2 (or 4 and 5) of the five-point Likert scale.
Results
Only six strategies out of 17 (35%) achieved consensus for both importance and feasibility. These strategies may therefore be considered the most important and feasible key strategies for improving safety culture in EDs. Seven strategies (41.1%) achieved consensus for importance, but not for feasibility and four strategies (23.55%) did not achieve consensus for either importance or feasibility.
Conclusions
This study offers practical solutions for safety culture improvement in the ED context. Six key strategies were seen as both important and feasible and these grouped into three main themes; leadership through agenda setting, operational management approaches to reinforce the agenda and commitment, and systems and structures to reinforce the agenda and monitor progress.
... Given 85% of intubations were immediately debriefed, we conclude immediate post-event debriefing is feasible. This is comparatively higher than 23% across 1 year with the DISCERN tool, 10 and similar success to that achieved by Rose and Cheng with the INFO tool. 18 A useful additional adjunct to enhance learning and QI is case summariesdistributed in 100% of intubations. ...
... Being so soon after the event, staff likely had good recall, as reported by Mullan et al. 20 This also had the advantage of bringing the team together while still on the same shift, avoiding the barrier of assembling the same team of shift workers at a later date. 10,21 Staff liked using the resuscitation room as the location for the debrief as they did not need to leave the clinical environment, minimising risk to other patients. It provided enough privacy to discuss cases and easy review of environment. ...
Objective
In 2013, our intubations highlighted a safety gap – only 49% achieved first-pass success without hypoxia or hypotension. NAP4 recommended debriefing after intubation, but limited published methods existed. Primary aim is to implement a feasible process for immediate debriefing and feedback for emergency airway management. Secondary aims are to contribute to reduced frequency of adverse intubation-related events and implement qualitative improvements in patient safety through team reflection and feedback.
Methods
A component of a prospective quality improvement (QI) study over 4 years in the ED of the Royal Children's Hospital, Melbourne, Australia. Debrief and feedback after intubation was one of seven study interventions. Targeted staff training and involvement of departmental leaders occurred. A post-intervention cohort was audited in 2016. Analysis included the Team Emergency Assessment Measure.
Results
Immediate post-event debriefing occurred in 39 (85%) of 46 intubations. Debriefing was short (median duration 5 min, interquartile range [IQR] 5–10) and soon after (median time 20 min, IQR 5–60). Commonest location was the resuscitation room (92%), led by the team leader (97%). Commonest barrier preventing immediate debriefing was excessive workload. Two QI process measures were assessed during debriefing (adequate resuscitation, airway plan) and case summaries distributed for 100% of intubations. Performance outcomes included contribution to 78% first-pass success without hypoxia or hypotension. Team reflection prompted changes to environment (signage, stickers), training (skill drills), teamwork and process (communication, clinical event debriefing).
Conclusion
Structured and targeted debriefing after intubating children in the ED is feasible and contributes to measurable and qualitative improvements in patient safety.
... The length of the interviews was approximately 15 minutes. The interviews were based on the Clinical Debriefing method [33], which led to an analysis of what was positive ('Plus)' and what could be improved ('Delta)'. ...
To date, it is still largely unclear how the changes, as a result of Covid-19, affect the work environment and the perceived organizational and managerial context (OMC). Through a mixed methods design, this study aims, (1) to identify changes in the hospital OMC before and during the first wave of the Covid-19 crisis; (2) to further analyze and compare the impact of the crisis on the perceptions of the staff. For the quantitative phase, questionnaire measuring the OMC was used in Covid and Non-Covid wards. For the qualitative phase, we performed semi-structured interviews to identify positive and negative elements from the crisis management. Results from linear mixed models highlighted multiple tendencies following the Covid crisis. Differences appeared between Covid and Non-Covid units, with the latter showing greater difficulties following the crisis. A significant increase in participants' scores on interprofessional relationships was reported (P < 0.05). We found a significant decrease in job satisfaction (P < 0.001), absence of burnout (P = 0.001) and perceived efficiency of the service (P < 0.001). These findings suggest that hospital management strategies should aim at providing transformational leadership and information flow, as well as equal support for all working units, so that healthcare professionals feel motivated and work towards a shared meaning.
... Most debriefings are noted to be physician-led [9,10,11]. Since physicians typically lead the patient care team, they are the seemingly obvious de facto choice for initiating and leading debriefs. However, some research has cautioned that team authority figures could inhibit or bias the discussion [9]. ...
... This modality allows participants to self-reflect on what went well and what needed improvement. In our situation, plus-delta is more advantageous because it can help busy healthcare staff to properly utilize the short time they are present there and allow debriefers to collect as many points as possible [3,[16][17][18][19][20][21][22][23]. The course' authors designed a standardized format for debriefers when using plus-delta to guide the discussion toward main objectives (Supplementary Material 1, Table S1, www.jocmr.org), ...
Background: Healthcare providers performing aerosol-generating procedures like airway management are at the highest risk for contamination with coronavirus disease 2019 (COVID-19). We developed an in-situ simulation (ISS) airway management training in confirmed or suspected COVID-19 patients for emergency and anesthesiology staff, evaluated participants’ reactions, and identified perceived challenges.
Methods: We used a cross-sectional study design incorporating a quantitative questionnaire to describe participants’ reaction to the ISS and a qualitative group interview using the plus-delta debriefing modality to explore participants’ challenges in acquiring the knowledge and skills required for each learning objective. Data were analyzed using descriptive statistics and deductive content analysis.
Results: Two hundred and ninety-nine healthcare providers participated in 62 ISS training sessions. Over 90% of our study participants agreed or strongly agreed that: they understood the learning objectives; the training material appropriately challenged them; the course content was relevant, easy to navigate, and essential; the facilitators’ knowledge, teaching, and style were appropriate; the simulation facilities were suitable; and they had ample opportunities to practice the learned skills. The main challenges identified were anticipating difficult airways, preparing intubation equipment, minimizing the number of personnel inside the room, adhering to the proper doffing sequence, preparing needed equipment outside the intubation room, speaking up, and ensuring closed-loop communication.
Conclusion: The newly developed ISS training was feasible for busy healthcare practitioners to safely perform airway management procedures for suspected or confirmed COVID-19 patients without affecting bedside care. Anticipation of difficult airways and speaking up were the most frequent challenges identified across all specialties in this study.
... Simulation offers opportunities for deliberate practice, adjustable clinical complexity, and regular execution of rare or complex events such as cardiac arrests [3]. Previous studies show the importance of simulation and training in teamwork dynamics (e.g., communication and leadership) on team performance, nontechnical skills, communication, and clinical outcomes [4][5][6][7][8][9]. For example, a trauma team simulation initiative demonstrated improved time-to-task completion, increased task completion, and increased teamwork scores, both during simulations, and sustained in observed real-life traumas following the simulation initiative [10]. ...
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.
... Examples of debriefing tools include, the "Promoting Excellence And Reflective Learning in Simulation (PEARLS)" health care debriefing tool, and the "Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN)" tool. [7][8][9] WRITTEN/ELECTRONIC CARE TOOLS Care tools encompass a broad range of resources that provide clinically relevant information that can assist in patient care and may be available in paper or electronic format. Electronic tools should have paper copies available in L&D for use during a power or Internet outage or other types of disasters that could involve the evacuation of the facility. ...
Utilization of emergency resources in obstetrics can help to optimize health care providers' care to pregnant and postpartum patients. There is a vast array of resources with various accessibility modalities that can be used before, during, and/or after an obstetric emergency. These resources can also be included as teaching material to increase knowledge and awareness with the aim to reduce maternal morbidity and mortality and improve patient outcomes.
... Clinical debriefing leads should disseminate the benefits of debriefing for improvement, wellbeing and resilience [4-9, 17, 24] in order to encourage staff to engage with debriefing processes. We suggest that CD sessions are brief and follow a structure familiar to the team such as TALK © [29], DIS-CERN [30], INFO [31], TeamSTEPPS [32] or DISCOVER-PHASE [33]. ...
The COVID-19 pandemic and the subsequent pressures on healthcare staff and resources have exacerbated the need for clinical teams to reflect and learn from workplace experiences. Surges in critically ill patients, the impact of the disease on the workforce and long term adjustments in work and life have upturned our normality. Whilst this situation has generated a new ‘connectedness’ within healthcare workers, it also continues to test our resilience.
An international multi-professional collaboration has guided the identification of ongoing difficulties to effective communication and debriefing, as well as emerging opportunities to promote a culture of dialogue. This article outlines pandemic related barriers and new possibilities categorising them according to task management, teamwork, situational awareness and decision making. It describes their direct and indirect impact on clinical debriefing and signposts towards solutions to overcome challenges and, building on new bridges, advance team conversations that allow us to learn, improve and support each other.
This pandemic has brought clinical professionals together; nevertheless, it is essential to invest in further developing and supporting cohesive teams. Debriefing enables healthcare teams and educators to mitigate stress, build resilience and promote a culture of continuous learning and patient care improvement.
... Although these predetermined compliance levels are below thresholds normally used for high reliability, 22 the study team chose them due to the infrequent levels of debriefing implemented in prior research studies. 19,23,24 ...
Introduction:
Pediatric quality improvement (QI) collaboratives are multisite clinical networks that support cooperative learning. Our goal is to identify the contextual facilitators and barriers to implementing QI resuscitation interventions within a multicenter resuscitation collaborative.
Methods:
A mixed-methods evaluation of the contextual facilitators and barriers to implementation of a resuscitation QI bundle. We administered a quantitative questionnaire, the Model for Understanding Success in Quality (MUSIQ), to the Pediatric Resuscitation Quality (pediRES-Q) Collaborative. Its primary goal is to optimize the care of children who experience in-hospital cardiac arrest through a resuscitation QI bundle. We also conducted semistructured phone interviews with site primary investigators adapted from the Consolidated Framework for Implementation Research qualitative interview guide.
Results:
All 13 actively participating US sites completed the MUSIQ questionnaire. Total MUSIQ scores ranged from 86.0 to 140.5 (median of 118.7, interquartile range 103.6-124.5). Evaluation of the QI team subsection noted a mean score of 5.5 for low implementers and 6.1 for high implementers (P = 0.02). We conducted 8 interviews with the local QI team leadership. Contextual facilitators included a unified institutional approach to QI, a fail forward climate, leadership support, strong microculture, knowledge of other organizations, and prioritization of goals. Contextual barriers included low team tenure, no specific allocation of resources, lack of formalized QI training, and lack of support and buy-in by leaders and staff.
Conclusions:
Using mixed methods, we identified an association between the local QI team's strength and the successful implementation of the QI interventions.
... Routine debriefing also facilitates understanding of system resources and constraints [11]. Debriefing methods have been largely adopted and adapted from aviation and psychology and there are many models of both post-simulation and clinical event debriefing [11][12][13][14][15][16][17][18][19]. ...
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.
... 35 Versions of PEARLS have been adapted for healthcare debriefing and systems-focused debriefing. 32 36 The Debriefing In-Situ Conversation after Emergent Resuscitation Now tool was developed in the study of resuscitations at a paediatric ED. 37 An adapted version was created during the COVID-19 pandemic for end-of-shift debriefing in EDs (Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End). 38 There is a large body of literature from medical simulation and other disciplines supporting critical event debriefing. ...
Aim:
To determine if data-informed debriefing, compared to a traditional debriefing, improves the process of care provided by healthcare teams during a simulated pediatric cardiac arrest.
Methods:
We conducted a prospective, randomized trial. Participants were randomized to a traditional debriefing or a data-informed debriefing supported by a debriefing tool. Participant teams managed a 10-minute cardiac arrest simulation case, followed by a debriefing (i.e. traditional or data-informed), and then a second cardiac arrest case. The primary outcome was the percentage of overall excellent CPR. The secondary outcomes were compliance with AHA guidelines for depth and rate, chest compression (CC) fraction, peri-shock pause duration, and time to critical interventions.
Results:
A total of 21 teams (84 participants) were enrolled, with data from 20 teams (80 participants) analyzed. The data-informed debriefing group was significantly better in percentage of overall excellent CPR (control vs intervention: 53.8% vs 78.7%; MD 24.9%, 95%CI: 5.4 to 44.4%, p = 0.02), guideline-compliant depth (control vs. intervention: 60.4% vs 85.8%, MD 25.4%, 95%CI: 5.5 to 45.3%, p = 0.02), CC fraction (control vs intervention: 88.6% vs 92.6, MD 4.0%, 95%CI: 0.5 to 7.4%, p = 0.03), and peri-shock pause duration (control vs intervention: 5.8 s vs 3.7 s, MD -2.1 s, 95%CI: -3.5 to -0.8 s, p = 0.004) compared to the control group. There was no significant difference in time to critical interventions between groups.
Conclusion:
When compared with traditional debriefing, data-informed debriefing improves CPR quality and reduces pauses in CPR during simulated cardiac arrest, with no improvement in time to critical interventions.
Objectives:
Interprofessional feedback and teamwork skills training are important in graduate medical education. Critical event debriefing is a unique interprofessional team training opportunity in the emergency department. While potentially educational, these varied, high-stakes events can threaten psychological safety for learners. This is a qualitative study of emergency medicine resident physicians' experience of interprofessional feedback during critical event debriefing to characterize factors that impact their psychological safety.
Methods:
The authors conduced semistructured interviews with resident physicians who were the physician team leader during a critical event debriefing. Interviews were coded and themes were generated using a general inductive approach and concepts from social ecological theory.
Results:
Eight residents were interviewed. The findings suggest that cultivating a safe learning environment for residents during debriefings involves the following: (1) allowing space for validating statements, (2) supporting strong interprofessional relationships, (3) providing structured opportunities for interprofessional learning, (4) encouraging attendings to model vulnerability, (5) standardizing the process of debriefing, (6) rejecting unprofessional behavior, and (7) creating the time and space for the process in the workplace.
Conclusions:
Given the numerous intrapersonal, interpersonal, and institutional factors at play, educators should be sensitive to times when a resident cannot engage due to unaddressed threats to their psychological safety. Educators can address these threats in real time and over the course of a resident's training to enhance psychological safety and the potential educational impact of critical event debriefing.
When health care professionals encounter child abuse and neglect, they can experience a range of emotions, such as anger, sadness, and frustration. Such feelings can cloud judgment, compromise care, or even undermine one's capacity to complete evaluation of a child. This article discusses key ethical values of honesty, objectivity, compassion, professionalism, respect for persons, and justice, which can be used to guide one's approaches to navigating secondary trauma during and after clinical interactions with children who have suffered abuse or neglect. Strategies for coping with intense feelings, especially during interactions with abused and neglected children's families, are also offered herein.
Background:
Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding.
Methods:
A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups.
Results:
Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue.
Conclusions:
Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.
Introduction:
A large-scale in situ simulation initiative on cardiac arrest in pregnancy was implemented across NYC Health + Hospitals. In situ simulation must be safely balanced with clinical conditions such as through application of no-go considerations or standardized reasons to cancel or postpone the simulation. Our objective is to describe our findings on the application of no-go considerations during this simulation initiative.
Methods:
NYC Health + Hospitals/Simulation Center developed an in situ simulation program focused on cardiac arrest in pregnancy, implemented at 11 acute care facilities. The program's toolkit included no-go considerations for in situ simulation safety: situations prompting a need to cancel, reschedule, or postpone a simulation to ensure patient and/or staff safety.
Results:
Data were collected from June 2018 through December 2019. The simulation sites reviewed the 13 established no-go considerations before each simulation event to assess if the simulation was safe to "go". After the conclusion of the initiative, all data related to no-go considerations were analyzed.Two hundred seventy-four in situ simulations were scheduled and 223 simulations (81%) were completed. Fifty-one no-go events were reported, with 78% identifying a reason by category. Twenty-two percent did not report a reason or category. Four of the 13 suggested no-go considerations were not reported.
Conclusions:
The no-go considerations framework promotes standardized and strategic scheduling of in situ simulation. Analysis of no-go consideration application during this system-wide initiative provides a model for the usage of tracking no-go data to enhance safety and inform future simulation planning.
Acute Critical Event Debriefing (ACED) after cardiopulmonary arrests should be the standard of care. However, little literature exists on how to implement performance-focused ACED in healthcare. Based on a series of successful ACED implementations in a variety of our settings, we describe key learnings and propose best practices to aid clinicians and organizations in establishing a successful ACED program. Within this practical guide, we also present a novel, standardized debriefing tool (Hotwash) that has been adapted for a variety of clinical settings.
Objectives:
The facilitated discussion of events through clinical event debriefing (CED) can promote learning and wellbeing, but resident involvement is often limited. Although the graduate medical education field supports CED, interventions to promote resident involvement are limited by poor insight into how residents experience CED. The objective of this study was to characterize pediatric resident experiences with CED, with a specific focus on practice barriers and facilitators.
Methods:
We conducted this qualitative study between November and December 2020 at a large, free-standing children's hospital. We recruited pediatric residents from postgraduate years 1 to 4 to participate in virtual focus groups. Focus groups were digitally recorded, deidentified, and transcribed. Transcripts were entered into coding software for analysis. We analyzed the data using a modified grounded theory approach to identify major themes.
Results:
We conducted 4 mixed-level focus groups with 26 residents. Our analysis identified multiple barriers and facilitators of resident involvement in CED. Several barriers were logistical in nature, but the most salient barriers were derived from unique features of the resident role. For example, residents described the transience of their role as a barrier to both participating and engaging in CED. However, they described advancing professional experience and the desire for reflective learning as facilitators.
Conclusions:
Residents in this study highlighted many factors affecting their participation and engagement in CED, including barriers related to the unique features of their role. On the basis of resident experiences, we propose several recommendations for CED practice that graduate medical education programs and hospitals should consider for supporting resident involvement in CED.
Objective. To provide guidelines to define the place of human factors in the management of critical situations in anesthesia and critical care.
Design. A committee of nineteen experts from SFAR and FHS group learned societies has been set up. A policy of declaration of links of interest was applied and respected throughout the whole process of producing guidelines. Likewise, it has not benefited from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.
Methods. We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organization, 3/ training and 4/ working environment. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.
Results. The experts' synthesis work and the application of the GRADE® method resulted in 21 recommendations. The GRADE® method could not be entirely applied to all questions, so the recommendations were formulated as expert opinions.
Conclusion. Based on a strong agreement between experts, we were able to produce 21
recommendations to guide human factors in critical situations.
Background
Debriefings help teams learn quickly and treat patients safely. However, many clinicians and educators report to struggle with leading debriefings. Little empirical knowledge on optimal debriefing processes is available. The aim of the study was to evaluate the potential of specific types of debriefer communication to trigger participants’ reflection in debriefings.
Methods
In this prospective observational, microanalytic interaction analysis study, we observed clinicians while they participated in healthcare team debriefings following three high-risk anaesthetic scenarios during simulation-based team training. Using the video-recorded debriefings and INTERACT coding software, we applied timed, event-based coding with DE-CODE, a coding scheme for assessing debriefing interactions. We used lag sequential analysis to explore the relationship between what debriefers and participants said. We hypothesised that combining advocacy (ie, stating an observation followed by an opinion) with an open-ended question would be associated with participants’ verbalisation of a mental model as a particular form of reflection.
Results
The 50 debriefings with overall 114 participants had a mean duration of 49.35 min (SD=8.89 min) and included 18 486 behavioural transitions. We detected significant behavioural linkages from debriefers’ observation to debriefers’ opinion (z=9.85, p<0.001), from opinion to debriefers’ open-ended question (z=9.52, p<0.001) and from open-ended question to participants’ mental model (z=7.41, p<0.001), supporting our hypothesis. Furthermore, participants shared mental models after debriefers paraphrased their statements and asked specific questions but not after debriefers appreciated their actions without asking any follow-up questions. Participants also triggered reflection among themselves, particularly by sharing personal anecdotes.
Conclusion
When debriefers pair their observations and opinions with open-ended questions, paraphrase participants’ statements and ask specific questions, they help participants reflect during debriefings.
Introduction:
Emergency nurses experience occupational stressors resulting from exposures to critical clinical events. The purpose of this study was to identify the critical clinical events for emergency nurses serving 3 patient populations (general, adult, pediatric) and whether the resilience of these nurses differed by the patient population served.
Methods:
This study used a cross-sectional survey design. A total of 48 emergency nurses were recruited from 3 trauma hospital-based emergency departments (general, adult, pediatric). Clinical Events Questionnaire, Connor-Davidson Resilience scale, and an investigator-developed demographic questionnaire were used to collect data from respondents.
Results:
All respondents were female (n = 48, 100%), and most were White (n = 46, 96%). The average age of participants was 39.6 years, the average number of years as a registered nurse was 12.7 years, and the average number of years as an emergency nurse was 8.8 years. Clinical events considered most critical were providing care to a sexually abused child, experiencing the death of a coworker, and lack of responsiveness by a colleague during a serious situation. The least stress-provoking event was incidents with excessive media coverage. Nurses were less affected by the critical events they experienced more frequently at work. Nurses in the 3 trauma settings had high level of resilience, with no statistically significant differences between groups.
Discussion:
The occupational stress from exposure to significant clinical events varied with the patient population served by emergency nurses. It is important that interventions be adopted to alleviate the effect of work-related stressors and promote the psychological health of emergency nurses.
Background
The emergency department witnesses the close functioning of an interdisciplinary team in an unpredictable environment. High stress situations can impact well-being and clinical practice both individually and as a team. Debriefing provides an opportunity for learning, validation, and conversation amongst individuals who may not typically discuss clinical experiences together.
The current study examined how a debriefing program could be designed and implemented in the emergency department so as to help teams and individuals learn from unique, stressful incidents.
Methods
Based on the theory of Workplace Based Learning and a design-based research approach, the evolved nature of a debriefing program implemented in the real-life context of the emergency department was examined. Focus groups were used to collect data. We report the design of the debriefing intervention as well as the program outcomes in terms of provider’s self-perceived roles in the program and program impact on provider’s self-reported clinical practice, as well as the redesign of the program based upon said feedback.
Results
The themes of barriers to debriefing, provision of perspectives, psychological trauma, and nurturing of staff emerged from focus group sessions.
Respondents identified barriers and concerns regarding debriefing, and based upon this information, changes were made to the program, including offering of refresher sessions for debriefing, inclusion of additional staff members in the training, and re-messaging the purpose of the program.
Conclusions
Data from the study reinforced the need to increase the frequency and availability of debriefing didactics along with clarifying staff roles in the program. Future work will examine continued impact on provider practice and influence on departmental culture.
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.
Education and clinical training in neurosurgical anesthesiology have seen tremendous progress, however, the need for more uniform and structured training is increasingly recognized by accreditation bodies. Clinical training highly depends on the availability of institutional cases, and it is difficult to perform an adequate assessment of skill competencies in rare and high-stakes clinical events. These challenges are best addressed by simulation-based education and training. In this chapter, we present basic concepts and guidelines for the development of a structured neurosurgical anesthesia simulation curriculum. Simulation education training is suitable for the identification of performance gaps, training and assessment of skill acquisition, training in rare, high-stakes events, anesthesia crisis resource management, and nontechnical skills (decision-making, communication, and multidisciplinary team training). We also present the basics of simulation scenarios development. Simulation scenarios are learner-oriented, competence-based tools that address identified clinical performance gaps. To accomplish the best educational objectives, the simulation education curriculum should always be well integrated with clinical training.
Background
Miscommunication is a common cause of medical errors and patient harm. Simulation is a good tool to improve communication skills, but there is little literature on advanced techniques to improve closed loop communication (CLC) in an effort to minimize medical errors. This study looks to evaluate whether blindfolding simulation participants is an effective tool in improving communication, and whether this advanced teaching technique is useful for critical pediatric scenarios.
Methods
Participants included Emergency Medicine (EM) residents and Pediatric EM fellows with Advanced Trauma Life Support (ATLS) certification. Participants were randomized into groups and completed a pediatric trauma scenario. Recorded simulations were reviewed by three independent faculty for primary objective measures of total instances of communication and CLC utilization during critical actions in the simulation. The secondary objective was the perceived stress load by participants when utilizing this teaching methodology. Wilcoxon rank sum test (WRS), Fisher’s exact test (FET), and Cochran-Armitage test (CAT) were utilized for statistical analysis.
Results
Statistically significant differences were noted in total communication between groups. Median and interquartile ranges (IQR) of total instances of communication were 17.0 (14.7-17.1) in non-blindfolded groups versus 21.0 (19.0-22.0) in blindfolded groups (p-value=0.002). Statistically significant increase in CLC was noted during the critical action of monitor placement in the blindfolded group (OR=13.7, 95% CI=1.4-133.8). No differences were noted in crisis resource management (CRM) scores. NASA Task Load Index (NASA-TLX) scores of both groups revealed similar stress levels. Statistical testing based upon the year of training was limited by small sample size and large number of categories.
Conclusions
Blindfolded simulations increased total instances of communication overall and improved CLC in one critical action without increasing stress levels. The blindfolded trauma simulation exercise is an effective advanced technique to reinforce CLC utilization and communication skills.
Developed by the leading experts in neonatal simulation, this innovative new resource delivers neonatology health care providers and educators essential guidance on designing, developing, and implementing simulation-based neonatal education programs. Available for purchase at https://shop.aap.org/neonatal-simulation-a-practical-guide-paperback/ (NOTE: This book features a full text reading experience. Click a chapter title to access content.)
Developed by the leading experts in neonatal simulation, this innovative new resource delivers neonatology health care providers and educators essential guidance on designing, developing, and implementing simulation-based neonatal education programs. Available for purchase at https://shop.aap.org/neonatal-simulation-a-practical-guide-paperback/ (NOTE: This book features a full text reading experience. Click a chapter title to access content.)
Purpose of review:
Although patient safety is a core component of education in anesthesiology, approaches to implementation of education programs are less well defined. The goal of this review is to describe the current state of education in anesthesia patient safety and the ideal patient safety curriculum.
Recent findings:
Anesthesiology has been a pioneer in patient safety for decades, with efforts amongst national organizations, such as the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation to disseminate key standards and guidelines in patient safety. However, few, if any strategies for implementation of a patient safety curriculum in anesthesiology exist.
Summary:
Patient safety education is crucial to the field of anesthesiology, particularly with the advancement of surgical and anesthesia technologies and increasing complexity of patients and procedures. The ideal patient safety curriculum in anesthesiology consists of simulation, adverse event investigation and analysis, and participation in process improvement. Efforts in education must adapt with changing technology, shifts in the way anesthesia care is delivered, and threats to physician wellness. Future efforts in education should harness emerging platforms, such as social media, podcasts, and wikis.
Purpose of review:
Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal critical event debriefing.
Recent findings:
Evidence-based key processes to consider for proximal critical event debriefing can be summarized by the WATER mnemonic: Welfare check (assessing team members' emotional and physical wellbeing to continue providing care); Acute/short-term corrections (matters to be addressed before the next case); Team reactions and reflections (summarizing case; listening to team member reactions; plus/delta conversation); Education (lessons learned from the event and debriefing); Resource awareness and longer term needs [follow-up (e.g. safety/quality improvement report), local peer-support and employee assistance resources]. A cognitive aid to accompany this mnemonic is provided with the publication.
Summary:
There is growing literature on how to conduct proximal perioperative critical event debriefing. Evidence-based best practices, as well as a cognitive aid to apply them, may help bridge the gap between theory and clinical practice. In this era of increased attention to burnout and wellness, the consideration of interventions to improve the quality and frequency of critical event debriefing is paramount.
Debriefing, a facilitator-guided reflection of an educational experience or critical incident, is an important tool in improving the safety and quality of practice in the NICU. Unlike feedback, which is often a one-way discussion, debriefing is a purposeful, 2-way reflective discussion which is based on experiential learning theory. The purpose of this article is to review the theoretical basis of debriefing and describe styles and tools for debriefing that can be applied in the NICU.
Objective:
To describe the use of a postarrest debriefing tool (DBT) within a university teaching hospital and to evaluate user perceptions of the tool.
Design:
Observational study over a 1-year period and associated hospital clinical personnel survey.
Setting:
University teaching hospital.
Interventions:
Qualitative data surrounding the use and utility of the DBT were analyzed, as well as survey results.
Measurements and main results:
Forty-four arrests occurred during the study period. Debriefing was performed after 26 of 44 (59%) cardiopulmonary resuscitation (CPR) events, of which 22 of 26 (85%) were recorded using the DBT and four without the DBT. Return of spontaneous circulation did not significantly affect the use of the DBT (p = 0.753). Most events in which debriefing was not performed occurred outside of business hours (13/18; 72%). The most frequent positive debriefing comments related to cooperation/coordination within the team (22/167; 13%). The most frequent negative debriefing comments concerned equipment issues (36/167; 22%). Of the action points generated, 57% (34/60) were directed at equipment use/availability. Teams reported that emergency drugs were appropriately administered in 21 of 22 (95%) cases. In contrast, closed loop communication was reportedly only used during 6 of 22 (27%) events. The hospital survey response rate was 56 of 338 (17%) clinical staff, of whom 37 of 56 (66%) agreed or strongly agreed that debriefing had improved team performance during CPR. Overall, 33 of 56 (60%) staff felt that the DBT had improved the debriefing process at the hospital. However, 3 of 56 (5%) staff members felt that they were unable to state their opinions in a blame-free environment during debriefing.
Conclusions:
Implementation of a DBT enabled formal identification of strengths and training needs of resuscitation teams, and its implementation was viewed positively by the majority of hospital staff. However, further refinement of the tool and prospective studies evaluating its efficacy in improving outcome are warranted.
Debriefing skills honed in simulation can be translated to the bedside with the goals to improve patient care and learn from real life clinical scenarios. Pediatric in-hospital cardiac arrest is associated with significant morbidity and mortality; debriefing afterwards has been demonstrated to improve patient outcomes. This chapter discusses the structures and processes of both “hot” and “cold” debriefing after clinical events, and describes how to optimize facilitators, address barriers, and manage difficult situations. Integration of debriefing into comprehensive resuscitation programs can improve resuscitation performance and patient outcomes.
Background
Emergency department nurses are faced with traumatic patient events while functioning as members of multidisciplinary teams. Postresuscitation debriefings have been shown to benefit health care professionals and patient clinical outcomes. The purpose of this study was to examine the relationship between the use of post resuscitation debriefings and perceptions of teamwork in emergency department nurses. The study also addressed the type and timing of debriefing to determine whether these factors are associated with perceptions of teamwork.
Methods
A nationwide survey was disseminated to emergency department nurses throughout the United States. The design aimed to compare the results from the Nursing Teamwork Survey with the data regarding frequency, type, and timing of debriefings. An ANOVA and Scheffe post hoc was done as well.
Results
The 68 responses which were included in the data were from 27 different states. Results showed that when debriefings were done more frequently (η = .41, p = .02), were conducted using a formal debriefing method (η = .36, p = .01), and were held immediately after a situation (η = .36, p = .03), there was a significant positive relationship (eta coefficient) with higher levels of trust, team orientation, backup, shared mental model, and leadership.
Conclusion
Findings may be used to increase utilization of debriefings and improve perceptions of teamwork among emergency department nurses.
La simulation est devenue un outil pédagogique incontournable dans la formation et le développement des professionnels de santé tant sur un plan individuel que sur le plan du travail en équipe. Cependant, face à l’utilisation croissante de la simulation pour les formations en santé, nombre de questions persistent quant aux mécanismes en jeu dans l’apprentissage par simulation ainsi qu’aux modalités pédagogiques à mettre en œuvre pour optimiser l’efficacité de ces formations. L’objectif de ce travail de thèse vise d’abord une meilleure compréhension du processus d’apprentissage expérientiel à l’œuvre lors d’une session d’apprentissage par simulation pour ensuite proposer une structuration des phases du débriefing susceptibles de favoriser l’acquisition de nouvelles connaissances déclaratives et procédurales. Une première étude a permis de montrer l’efficacité de la mise en place de situations simulées lors des formations aux gestes et soins d’urgence. Une deuxième étude a confirmé l’intérêt d’un programme de simulation construit selon les principes d’apprentissage expérientiel de Kolb (1984) sur les réactions, apprentissages et comportements de soignants expérimentés travaillant en équipes pluri-professionnelles de structure mobile d’urgence et de réanimation (SMUR). Ce travail s’est ensuite centré sur la place accordée au débriefing dans l’apprentissage par simulation. Une troisième étude a précisé la place du débriefing dans l’évolution du sentiment d’efficacité personnelle des apprenants et, dans la lignée des travaux sur l’enseignement explicite, a montré la supériorité des approches structurées et explicites du débriefing par rapport aux approches implicites et réflexives pour l’apprentissage de connaissances déclaratives chez les apprenants novices (étudiants infirmiers). Une quatrième étude a ensuite montré que, pour des apprenants expérimentés en équipes pluri-professionnelles de service d’urgence, le débriefing explicite s’avérait aussi efficace qu’un débriefing réflexif sur l’évolution des connaissances déclaratives, du sentiment d’efficacité personnelle ainsi que sur les modifications comportementales. Sur un plan pragmatique, les résultats de ce travail apportent des éléments pour la mise en œuvre d’une session d’apprentissage par simulation en santé et notamment sur la manière de structurer les différentes séquences de débriefing selon le public considéré.
Objectives:
Event debriefing has established benefit, but its adoption is poorly characterized among pediatric ward providers. To improve patient safety, our hospital restructured its debriefing process for ward deterioration events culminating in ICU transfer. The aim of this study was to describe this process' implementation.
Methods:
In the restructured process, multidisciplinary ward providers are expected to debrief all ICU transfers. We conducted a multimethod analysis using facilitative guides completed by debriefing participants. Monthly debriefing completion served as an adoption metric.
Results:
Between March 2019 and February 2020, providers across 9 wards performed debriefing for 134 of 312 PICU transfers (43%). Bedside nurses participated most frequently (117 debriefings [87%]). There was no significant difference in debriefing by unit, acuity, season, or nurse staffing. Compared with units fully staffed by rotational frontline clinicians (FLCs; eg, resident physicians), units with dedicated FLCs whose responsibilities are primarily limited to that unit (eg, oncology hospitalists) completed significantly more monthly debriefings (average [SD] 57% [30%] vs 33% [28%] of PICU transfers; P = .004). FLC participation was also higher on these units (50% of debriefings [37%] vs 24% [37%]; P = .014). Through qualitative analysis, we identified distinct debriefing themes, with teaming activities such as communication cited most often.
Conclusions:
Implementation of a multidisciplinary debriefing process for ward deterioration events culminating in ICU transfer was associated with differential adoption across providers and FLC staffing models but not acuity or nurse staffing. Teaming activities were a debriefing priority. Future study will assess patient safety outcomes.
Background
Prior to the study, debriefings post-real-life cardiopulmonary arrest at the associated hospital were conducted only 3% of the time. However, debriefings post-cardiopulmonary arrests are recommended by multiple entities to improve team performance.
Methods
A course on teamwork, education on a structured method of debriefing, and debriefing practice via simulated role-play were provided to resuscitation team members. A prospective, mixed methods study including team member perceptions of debriefings and the number of debriefings conducted post-cardiopulmonary arrests were measured after the intervention.
Results
Debriefings increased from 3% to 39%. Debriefings were valued by all team members. Themes generated from team members’ comments included improvement, communication, and team function.
Conclusions
Debriefings post-real-life cardiopulmonary arrest events are feasible in a hospital setting. Teamwork principles training with simulated role-play of debriefing can impact the process of whether debriefings occur and are highly regarded by multidisciplinary team members.
Cardiac arrest affects 30-35, 000 hospitalised patients in the UK every year. For these patients to be given the best chance of survival, high quality cardiopulmonary resuscitation (CPR) must be delivered, however the quality of CPR in real-life is often suboptimal. CPR feedback devices have been shown to improve CPR quality in the pre-hospital setting and post-event debriefing can improve adherence to guidelines and CPR quality. However, the evidence for use of these improvement methods in hospital remains unclear. The CPR quality improvement initiative is a prospective cohort study of the Q-CPR real-time feedback device combined with post-event debriefing in hospitalised adult patients who sustain a cardiac arrest.
The primary objective of this trial is to assess whether a CPR quality improvement initiative will improve rate of return of sustained spontaneous circulation in in-hospital-cardiac-arrest patients. The study is set in one NHS trust operating three hospital sites. Secondary objectives will evaluate: any return of spontaneous circulation; survival to hospital discharge and patient cerebral performance category at discharge; quality of CPR variables and cardiac arrest team factors. Methods: All three sites will have an initial control phase before any improvements are implemented; site 1 will implement audiovisual feedback combined with post event debriefing, site 2 will implement audiovisual feedback only and site 3 will remain as a control site to measure any changes in outcome due to any other trust-wide changes in resuscitation practice. All adult patients sustaining a cardiac arrest and receiving resuscitation from the hospital cardiac arrest team will be included. Patients will be excluded if; they have a Do-not-attempt resuscitation order written and documented in their medical records, the cardiac arrest is not attended by a resuscitation team, the arrest occurs out-of-hospital or the patient has previously participated in this study. The trial will recruit a total of 912 patients from the three hospital sites.
This trial will evaluate patient and process focussed outcomes following the implementation of a CPR quality improvement initiative using real-time audiovisual feedback and post event debriefing.
ISRCTN56583860.
Qualitative methods are now widely used and increasingly accepted in health research, but quality in qualitative research is a mystery to many health services researchers. There is considerable debate over the nature of the knowledge produced by such methods and how such research should be judged. Antirealists argue that qualitative and quantitative research are very different and that it is not possible to judge qualitative research by using conventional criteria such as reliability, validity, and generalisability. Quality in qualitative research can be assessed with the same broad concepts of validity and relevance used for quantitative research, but these need to be operationalised differently to take into account the distinctive goals of qualitative research.
This review examines current research on teamwork in highly dynamic domains of healthcare such as operating rooms, intensive care, emergency medicine, or trauma and resuscitation teams with a focus on aspects relevant to the quality and safety of patient care.
Evidence from three main areas of research supports the relationship between teamwork and patient safety: (1) Studies investigating the factors contributing to critical incidents and adverse events have shown that teamwork plays an important role in the causation and prevention of adverse events. (2) Research focusing on healthcare providers' perceptions of teamwork demonstrated that (a) staff's perceptions of teamwork and attitudes toward safety-relevant team behavior were related to the quality and safety of patient care and (b) perceptions of teamwork and leadership style are associated with staff well-being, which may impact clinician' ability to provide safe patient care. (3) Observational studies on teamwork behaviors related to high clinical performance have identified patterns of communication, coordination, and leadership that support effective teamwork.
In recent years, research using diverse methodological approaches has led to significant progress in team research in healthcare. The challenge for future research is to further develop and validate instruments for team performance assessment and to develop sound theoretical models of team performance in dynamic medical domains integrating evidence from all three areas of team research identified in this review. This will help to improve team training efforts and aid the design of clinical work systems supporting effective teamwork and safe patient care.
The survival benefit of well-performed cardiopulmonary resuscitation (CPR) is well-documented, but little objective data exist regarding actual CPR quality during cardiac arrest. Recent studies have challenged the notion that CPR is uniformly performed according to established international guidelines.
To measure multiple parameters of in-hospital CPR quality and to determine compliance with published American Heart Association and international guidelines.
A prospective observational study of 67 patients who experienced in-hospital cardiac arrest at the University of Chicago Hospitals, Chicago, Ill, between December 11, 2002, and April 5, 2004. Using a monitor/defibrillator with novel additional sensing capabilities, the parameters of CPR quality including chest compression rate, compression depth, ventilation rate, and the fraction of arrest time without chest compressions (no-flow fraction) were recorded.
Adherence to American Heart Association and international CPR guidelines.
Analysis of the first 5 minutes of each resuscitation by 30-second segments revealed that chest compression rates were less than 90/min in 28.1% of segments. Compression depth was too shallow (defined as <38 mm) for 37.4% of compressions. Ventilation rates were high, with 60.9% of segments containing a rate of more than 20/min. Additionally, the mean (SD) no-flow fraction was 0.24 (0.18). A 10-second pause each minute of arrest would yield a no-flow fraction of 0.17. A total of 27 patients (40.3%) achieved return of spontaneous circulation and 7 (10.4%) were discharged from the hospital.
In this study of in-hospital cardiac arrest, the quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations, even when performed by well-trained hospital staff. The importance of high-quality CPR suggests the need for rescuer feedback and monitoring of CPR quality during resuscitation efforts.
Cardiopulmonary resuscitation (CPR) guidelines recommend target values for compressions, ventilations, and CPR-free intervals allowed for rhythm analysis and defibrillation. There is little information on adherence to these guidelines during advanced cardiac life support in the field.
To measure the quality of out-of-hospital CPR performed by ambulance personnel, as measured by adherence to CPR guidelines.
Case series of 176 adult patients with out-of-hospital cardiac arrest treated by paramedics and nurse anesthetists in Stockholm, Sweden, London, England, and Akershus, Norway, between March 2002 and October 2003. The defibrillators recorded chest compressions via a sternal pad fitted with an accelerometer and ventilations by changes in thoracic impedance between the defibrillator pads, in addition to standard event and electrocardiographic recordings.
Adherence to international guidelines for CPR.
Chest compressions were not given 48% (95% CI, 45%-51%) of the time without spontaneous circulation; this percentage was 38% (95% CI, 36%-41%) when subtracting the time necessary for electrocardiographic analysis and defibrillation. Combining these data with a mean compression rate of 121/min (95% CI, 118-124/min) when compressions were given resulted in a mean compression rate of 64/min (95% CI, 61-67/min). Mean compression depth was 34 mm (95% CI, 33-35 mm), 28% (95% CI, 24%-32%) of the compressions had a depth of 38 mm to 51 mm (guidelines recommendation), and the compression part of the duty cycle was 42% (95% CI, 41%-42%). A mean of 11 (95% CI, 11-12) ventilations were given per minute. Sixty-one patients (35%) had return of spontaneous circulation, and 5 of 6 patients discharged alive from the hospital had normal neurological outcomes.
In this study of CPR during out-of-hospital cardiac arrest, chest compressions were not delivered half of the time, and most compressions were too shallow. Electrocardiographic analysis and defibrillation accounted for only small parts of intervals without chest compressions.
To investigate the emotional reactions of registrars following the death of a child.
A multicentre study to determine the sources of support for registrars and the use of debriefing following a child's death. A questionnaire was sent or given to registrars within the South West Region.
There was a 75% response rate; 71% of registrars felt they had initial support but limited ongoing support and 69% of registrars supported junior colleagues. There was debriefing in 31% of cases.
More accessible and constructive support for staff needs to be developed following a patient's death.
Debriefing is a form of psychological "first aid" with origins in the military. It moved into the spotlight in 1983, when Mitchell described the technique of critical incident stress debriefing. To date little work has been carried out relating to the effectiveness of debriefing hospital staff after critical incidents. The aim of this study was to survey current UK practice in order to develop some "best practice" guidelines.
This study was a descriptive evaluation based on a structured questionnaire survey of 180 lead paediatric and emergency medicine consultants and nurses, selected from 50 UK trusts. Questions collected data about trust policy and events and also about individuals' personal experience of debrief. Free text comments were analyzed using the framework method described for qualitative data.
Overall, the response rate was 80%. 62% said a debrief would occur most of the time. 85% reported that the main aim was to resolve both medical and psychological and emotional issues. Nearly all involve both doctors and nurses (88%); in over half (62%) other healthcare workers would be invited, eg, paramedics, students. Sessions are usually led by someone who was involved in the resuscitation attempt (76%). This was a doctor in 80%, but only 18% of responders said that a specifically trained person had led the session. Individuals' psychological issues would be discussed further on a one-to-one basis and the person directed to appropriate agencies. Any strategic working problems highlighted would be discussed with a senior member of staff and resolved via clinical governance pathways.
Little is currently known about the benefits of debriefing hospital staff after critical incidents such as failed resuscitation. Debriefing is, however, widely practised and the results of this study have been used to formulate some best practice guidelines while awaiting evidence from further studies.
Recent investigations have documented poor cardiopulmonary resuscitation (CPR) performance in clinical practice. We hypothesized that a debriefing intervention using CPR quality data from actual in-hospital cardiac arrests (resuscitation with actual performance integrated debriefing [RAPID]) would improve CPR performance and initial patient survival.
Internal medicine residents at a university hospital attended weekly debriefing sessions of the prior week's resuscitations, between March 2006 and February 2007, reviewing CPR performance transcripts obtained from a CPR-sensing and feedback-enabled defibrillator. Objective metrics of CPR performance and initial return of spontaneous circulation were compared with a historical cohort in which a similar feedback-delivering defibrillator was used but without RAPID.
Cardiopulmonary resuscitation quality and outcome data from 123 patients resuscitated during the intervention period were compared with 101 patients in the baseline cohort. Compared with the control period, the mean (SD) ventilation rate decreased (13 [7]/min vs 18 [8]/min; P < .001) and compression depth increased (50 [10] vs 44 [10] mm; P = .001), among other CPR improvements. These changes correlated with an increase in the rate of return of spontaneous circulation in the RAPID group (59.4% vs 44.6%; P = .03) but no change in survival to discharge (7.4% vs 8.9%; P = .69).
The combination of RAPID and real-time audiovisual feedback improved CPR quality compared with the use of feedback alone and was associated with an increased rate of return of spontaneous circulation. Cardiopulmonary resuscitation sensing and recording devices allow for methods of debriefing that were previously available only for simulation-based education; such methods have the potential to fundamentally alter resuscitation training and improve patient outcomes.
clinicaltrials.gov Identifier: NCT00228293.
Anecdotally critical incident debriefing (CID) is an important topic for staff in paediatric ED. The present study aimed to determine current baseline CID practices and perceived needs of ED staff. A questionnaire regarding CID practice was circulated to all 13 Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites in Australia and New Zealand (including all tertiary paediatric ED), and completed by 1 senior doctor and 1 senior nurse. All PREDICT sites participated (13 nurses, 13 doctors). Seventy per cent did not currently have a hospital protocol on debriefing and 90% did not have ED-specific guidelines. The most commonly debriefed topics were death of a patient, multi-trauma and sudden infant death syndrome, also ranked highest in importance for debriefing. The median reported debriefs per department were 4 per year (range 0–12), all conducted within a week of the CI with half within 24 h. ED workers most likely to be invited to the CID session were doctors, nurses and social workers (96%). Debriefing was mostly conducted internally (62%) and most likely facilitated by a doctor (81%) or nurse (54%). Debriefing addressed both clinical and emotional issues (89%) within the same session (69%). Debriefing was rated as very important, median of 8/10 by doctors and 10/10 by nurses. Almost 90% of those surveyed indicated that they would like a CID programme and guidelines for their department. Debriefing is perceived as important by senior ED clinicians, yet few ED have formalized guidelines or programmes. Best-practice guidelines should be developed.
Our primary objective was to describe and determine the feasibility of implementing a care environment targeted pediatric post-cardiac arrest debriefing program. A secondary objective was to evaluate the usefulness of debriefing content items. We hypothesized that a care environment targeted post-cardiac arrest debriefing program would be feasible, well-received, and result in improved self-reported knowledge, confidence and performance of pediatric providers.
Physician-led multidisciplinary pediatric post-cardiac arrest debriefings were conducted using data from CPR recording defibrillators/central monitors followed by a semi-quantitative survey. Eight debriefing content elements divided, a priori, into physical skill (PS) related and cognitive skill (CS) related categories were evaluated on a 5-point Likert scale to determine those most useful (5-point Likert scale: 1=very useful/5=not useful). Summary scores evaluated the impact on providers' knowledge, confidence, and performance.
Between June 2010 and May 2011, 6 debriefings were completed. Thirty-four of 50 (68%) front line care providers attended the debriefings and completed surveys. All eight content elements were rated between useful to very useful (Median 1; IQR 1-2). PS items scored higher than CS items to improve knowledge (Median: 2 (IQR 1-3) vs. 1 (IQR 0-2); p<0.02) and performance (Median: 2 (IQR 1-3) vs. 1 (IQR 0-1); p<0.01).
A novel care environment targeted pediatric post-cardiac arrest pediatric debriefing program is feasible and useful for providers regardless of their participation in the resuscitation. Physical skill related elements were rated more useful than cognitive skill related elements for knowledge and performance.
Emergency department (ED) resuscitation requires the coordinated efforts of an interdisciplinary team. Human errors are common and have a negative impact on patient safety. Although crisis resource management (CRM) skills are utilized in other clinical domains, most emergency medicine (EM) caregivers currently receive no formal CRM training.
The objectives were to compile and compare attitudes toward CRM training among EM staff physicians, nurses, and residents at two Canadian academic teaching hospitals.
Emergency physicians (EPs), residents, and nurses were asked to complete a Web survey that included Likert scales and short answer questions. Focus groups and pilot testing were used to inform survey development. Thematic content analysis was performed on the qualitative data set and compared to quantitative results.
The response rate was 75.7% (N = 84). There was strong consensus regarding the importance of core CRM principles (i.e., effective communication, team leadership, resource utilization, problem-solving, situational awareness) in ED resuscitation. Problems with coordinating team actions (58.8%), communication (69.6%), and establishing priorities (41.3%) were among factors implicated in adverse events. Interdisciplinary collaboration (95.1%), efficiency of patient care (83.9%), and decreased medical error (82.6%) were proposed benefits of CRM training. Communication between disciplines is a barrier to effective ED resuscitation for 94.4% of nurses and 59.7% of EPs (p = 0.008). Residents reported a lack of exposure to (64.3%), yet had interest in (96.4%) formal CRM education using human patient simulation.
Nurses rate communication as a barrier to teamwork more frequently than physicians. EM residents are keen to learn CRM skills. An opportunity exists to create a novel interdisciplinary CRM curriculum to improve EM team performance and mitigate human error.
The fast-paced and multifaceted nature of patient care in the emergency department makes our discipline especially prone to errors and adverse events. In recent years, strategies such as formal communication and medical team training have been proposed as potential means to enhance patient safety. In many ways, practice dynamics particular to the emergency department make this setting almost ideal for implementation of these strategies. This article reviews concepts of communication and team training in medicine, including those learned from the aviation industry (known as crew resource management). Recent literature pertaining to teams and communication in medicine is reviewed.
Optimizing the links in the Chain of Survival improves outcomes and saves lives. The use of evidence-based education and implementation strategies will allow organizations and communities to strengthen these links in the most effective and efficient manner.
The aim of this study was to develop a systematic review using international research to describe the role of teamwork and communication in the emergency department, and its relevance to physiotherapy practice in the emergency department. Searches were conducted of CINAHL, Academic Search Premier, Scopus, Cochrane, PEDro, Medline, Embase, Amed and PubMed. Selection criteria included full-text English language research papers related to teamwork and/or communication based directly in the emergency department, involvement of any profession in the emergency department, publication in peer-reviewed journals, and related to adult emergency services. Studies were appraised using a validated critical appraisal tool. Fourteen eligible studies, all of mid-range quality, were identified. They demonstrated high levels of staff satisfaction with teamwork training interventions and positive staff attitudes towards the importance of teamwork and communication. There is moderate evidence that the introduction of multidisciplinary teams to the ED may be successful in reducing access block, and physiotherapists may play a role in this. The need for teamwork and communication in the ED is paramount, and their roles are closely linked, with the common significant purposes of improving patient safety, reducing clinical errors, and reducing waiting times.
To develop a valid, reliable and feasible teamwork assessment measure for emergency resuscitation team performance.
Generic and profession specific team performance assessment measures are available (e.g. anaesthetics) but there are no specific measures for the assessment of emergency resuscitation team performance.
(1) An extensive review of the literature for teamwork instruments, and (2) development of a draft instrument with an expert clinical team. (3) Review by an international team of seven independent experts for face and content validity. (4) Instrument testing on 56 video-recorded hospital and simulated resuscitation events for construct, consistency, concurrent validity and reliability and (5) a final set of ratings for feasibility on fifteen simulated 'real time' events.
Following expert review, selected items were found to have a high total content validity index of 0.96. A single 'teamwork' construct was identified with an internal consistency of 0.89. Correlation between the total item score and global rating (rho 0.95; p<0.01) indicated concurrent validity. Inter-rater (k 0.55) and retest reliability (k 0.53) were 'fair', with positive feasibility ratings following 'real time' testing. The final 12 item (11 specific and 1 global rating) are rated using a five-point scale and cover three categories leadership, teamwork and task management.
In this primary study TEAM was found to be a valid and reliable instrument and should be a useful addition to clinicians' tool set for the measurement of teamwork during medical emergencies. Further evaluation of the instrument is warranted to fully determine its psychometric properties.
The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic review of high fidelity simulation literature identified feedback (including debriefing) as the most important feature of simulation-based medical education. 1 Despite this, there are surprisingly few papers in the peer-reviewed literature to illustrate how to debrief, how to teach or learn to debrief, what methods of debriefing exist and how effective they are at achieving learning objectives and goals. This review is by no means a systematic review of all the literature available on debriefing, and contains information from both peer and nonpeer reviewed sources such as meeting abstracts and presentations from within the medical field and other disciplines versed in the practice of debriefing such as military, psychology, and business. It also contains many examples of what expert facilitators have learned over years of practice in the area. We feel this would be of interest to novices in the field as an introduction to debriefing, and to experts to illustrate the gaps that currently exist, which might be addressed in further research within the medical simulation community and in collaborative ventures between other disciplines experienced in the art of debriefing.
Background:
Medical teams are commonly called on to perform complex tasks, and when those tasks involve saving the lives of critically injured patients, it is imperative that teams perform optimally. Yet, medical care settings do not always lend themselves to efficient teamwork. The human factors and occupational sciences literatures concerning the optimization of team performance suggest the usefulness of a debriefing process--either for critical incidents or recurring events. Although the debrief meeting is often used in the context of training medical teams, it is also useful as a continuous learning tool throughout the life of the team. WHAT ARE GOOD DEBRIEFS?
An overview:
The debriefing process allows individuals to discuss individual and team-level performance, identify errors made, and develop a plan to improve their next performance.
Best practices and tips for debriefing teams:
THE DEBRIEF PROCESS: The list of 12 best practices and tips--4 for hospital leaders and the remainder for debrief facilitators or team leaders--should be useful for teams performing in various high-risk areas, including operating rooms, intensive care units, and emergency departments. The best practices and tips should help teams to identify weak areas of teamwork and develop new strategies to improve teamwork competencies. Moreover, they include practices that support both regular, recurring debriefs and critical-incident debriefings. Team members should follow these main guidelines--also provided in checklist form--which include ensuring that the organization creates a supportive learning environment for debriefs (concentrating on a few critical performance issues), providing feedback to all team members, and recording conclusions made and goals set during the debrief to facilitate future feedback.
This is a descriptive study of questionnaire responses of 682 members of three state ENAs, with supporting interview data from 26 of those participants. The objective was to determine (1) the types of clinical events perceived as critical and (2) the usefulness of critical incident stress debriefings for emergency nurses.
Questionnaires asking emergency nurses to rate clinical incidents as critical and to respond to questions about their experiences with debriefings were sent to members of three state ENAs. Structured interviews about personal experiences with critical incidents and debriefings were conducted with 26 respondents.
Emergency nurses responding to the questionnaire viewed the death of a child and the death of a coworker as the most critical of the possible events. The majority of interviewees saw an incident related to the death of a child as the most critical in their careers. Of the questionnaire respondents, 32% had participated in debriefings; 88% of those found them helpful in reducing critical incident stress.
The findings suggest that managers should be alerted to the possibility of acute stress responses when emergency nurses experience a child's death. Education regarding stress and debriefings may be helpful to ED personnel.
Effective communication enhances team building and is perceived to improve the quality of team performance. A recent publication from the Resuscitation Council (UK) has highlighted this fact and recommended that cardiac arrest team members make contact daily. We wished to identify how often members of this team communicate prior to a cardiopulmonary arrest.
A questionnaire on cardiac arrest team composition, leadership, communication and debriefing was distributed nationally to Resuscitation Training Officers (RTOs) and their responses analysed.
One hundred and thirty (55%) RTOs replied. Physicians and anaesthetists were the most prominent members of the team. The Medical Senior House Officer is usually nominated as the team leader. Eighty-seven centres (67%) have no communication between team members prior to attending a cardiopulmonary arrest. In 33%, communication occurs but is either informal or fortuitous. The RTOs felt that communication is important to enhance team dynamics and optimise task allocation. Only 7% achieve a formal debrief following a cardiac arrest.
Communication between members of the cardiac arrest team before and after a cardiac arrest is poor. Training and development of these skills may improve performance and should be prioritised. Team leadership does not necessarily reflect experience or training.
Performance review using videotapes is a strategy employed to improve future performance. We postulated that videotape review of trauma resuscitations would improve compliance with a treatment algorithm.
Trauma resuscitations were taped and reviewed during a 6-month period. For 3 months, team members were given verbal feedback regarding performance. During the next 3 months, new teams attended videotape reviews of their performance. Data on targeted behaviors were compared between the two groups.
Behavior did not change after 3 months of verbal feedback; however, behavior improved after 1 month of videotape feedback (P <0.05) and total time to disposition was reduced by 50% (P <0.01). This response was sustained for the remainder of the study.
Videotape review can be an important learning tool as it was more effective than verbal feedback in achieving behavioral changes and algorithm compliance. Videotape review can be an important quality assurance adjunct, as improved algorithm compliance should be associated with improved patient care.
To describe residents' exposure and reactions to pediatric deaths, their debriefing experiences, and factors associated with debriefing.
Cross-sectional survey completed at the end of residency. The survey reflected experiences from the prior 18 months concerning number, type, and setting of deaths; resident reactions; whether resident debriefed and with whom after a patient's death.
Seventy-four residents (84%) completed the survey over 4 academic years accounting for 363 deaths; 59% were inpatient deaths of patients with chronic diseases, 22% were inpatient, 18% were emergency department (ED) deaths of previously healthy patients, and 1% were deaths of patients with chronic diseases who died in the ED or in their home. Mean number of deaths experienced per resident was 4.6 (range, 0-19). Thirty-one percent of residents expressed guilt, and 74% stated they had debriefed at least one time, but debriefings took place after only 30% of deaths. Resident debriefing was associated with an inpatient death of a previously healthy child, OR 5.3 (95% CI: 1.31, 22.3), P=.01, whereas there was not an association with number of previous deaths, acute outpatient or chronic inpatient deaths, or resident guilt.
Pediatric residents were involved in a small number but varying types of death experiences. Debriefing took place after a minority of deaths. Future research needs to investigate the potential benefits of debriefing.
Verbal communication is essential for teamwork and leadership in high-intensity performances like trauma resuscitation. We evaluated communication during multidisciplinary trauma resuscitation.
The main trauma room of a level one trauma centre was equipped with a digital video recording system. Resuscitations were consecutively and prospectively enrolled. Patients with revised trauma score (RTS)=12 were resuscitated by a 'minor trauma team' and patients with RTS<12 by a 'major trauma team'. Information transferral from physicians to other team members was evaluated separately for all ABCDE's, according to initiation, audibility and response. The observer was trained and the first 30 video's were excluded.
From May 1st to September 1st 2003, 205 resuscitations were included, 12 were lost for evaluation. The 'major trauma team' resuscitated 74 patients (ISS:21.4). Communication was audible in 56% and understandable in 44% during the primary survey. The 'minor trauma team' assessed 119 patients (ISS:7.4). Communication was audible in 43% and understandable in 33%.
Communication during trauma resuscitation was found to be sub optimal. This is potentially harmful for trauma victims. Professionals and institutions should be aware that communication is not self-evident. Introduction of an aviation-like communication feedback system could help to optimise trauma care.
We aimed to determine internal medicine residents' perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal.
Cross-sectional postal survey.
Canadian internal medicine training programs.
Internal medicine residents attending Canadian English-speaking medical schools.
A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools.
Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r(2) = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence.
The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.
Patient safety is a priority for all health care professionals, including those who work in emergency care. Unique aspects of pediatric care may increase the risk of medical error and harm to patients, especially in the emergency care setting. Although errors can happen despite the best human efforts, given the right set of circumstances, health care professionals must work proactively to improve safety in the pediatric emergency care system. Specific recommendations to improve pediatric patient safety in the emergency department are provided in this policy statement.
The field of team training is quickly evolving and data are emerging to support the close relationship between effective teamwork and patient safety in medicine. This paper provides a review of the literature on team training with specific emphasis on the perspectives of emergency and critical care pediatricians.
Errors in medicine are most frequently due to an interaction of human factors like poor teamwork and poor communication rather than individual mistakes. Critical care settings and those in which patients are at the extremes of age are particularly high-risk, making emergency and critical care pediatrics a special area of concern. Team training is one approach for reducing error and enhancing patient safety. Currently, there is no single standard for team training in medicine, but multiple disciplines, including anesthesiology, emergency medicine and neonatology, have adapted key principles from other high-reliability industries such as aviation into crisis resource management training.
Team training holds promise to improve patient safety in pediatric emergency departments and critical care settings. We must carefully delineate the optimal instructional strategies to improve team behaviors and combine these with rigorous outcomes assessment to diagnose team problems and prescribe targeted solutions, and determine their long-term impact on patient safety.
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