No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
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.
... Given the lack of published clinical debriefing tools for behavioral events in the pediatric ED and hospital settings, the team adapted a previously published clinical debriefing tool that has been adapted to multiple other settings. 38 Similar to prior clinical debriefing tools, the primary goal of debriefing was for the team to collaboratively learn from the event to prevent future events for this patient, improve the team's future performance, and identify systems-based factors that might have enabled or prevented specific outcomes. [38][39][40][41][42] Functionally, the implementation team aimed to create a standardized tool that would be easily accessible, simple to facilitate with minimal training, fast to complete, and medicolegally protected from discoverability as a Patient Safety Work Product (PSWP) as defined by the Patient Safety Act and Patient Safety Rule. ...
... 38 Similar to prior clinical debriefing tools, the primary goal of debriefing was for the team to collaboratively learn from the event to prevent future events for this patient, improve the team's future performance, and identify systems-based factors that might have enabled or prevented specific outcomes. [38][39][40][41][42] Functionally, the implementation team aimed to create a standardized tool that would be easily accessible, simple to facilitate with minimal training, fast to complete, and medicolegally protected from discoverability as a Patient Safety Work Product (PSWP) as defined by the Patient Safety Act and Patient Safety Rule. 43 The tool was designed to be performed as a "hot debriefing" which occurs in the minutes to hours after an event has stabilized. ...
... The plus-delta model for clinical debriefing is used to gather team input with questions that focus on what went well (plus questions), what could be improved to enhance future performance (delta questions), and what triggers contributed to the behavioral alert (trigger questions). 38 The debriefing tool also includes a non-documented question to check in with everyone on how they were doing, the instructions for forwarding the completed debriefing form, and information on how staff can seek emotional support for themselves if needed. The clinical debriefing is not intended to be used as a psychological debriefing, as performed in Critical Incident Stress Debriefing or psychological first aid, but it does provide this moment for team members to pause and reflect on any emotions from the experience and refer anyone who is significantly affected to secondary resources for additional assistance. ...
... 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.
... 9,10 Accordingly, multiple professional groups regard CED as a best practice in hospital-based care, including the American Heart Association, who recommend CED to improve clinical performance in resuscitation events. 2,11,12 CED may occur soon after an event (ie, "hot" CED) or at a delay (ie, "cold" CED). However, published CED practices vary widely, 2,9,13,14 and most recommendations come from the simulation and resuscitation literatures. ...
... 2,11,12 CED may occur soon after an event (ie, "hot" CED) or at a delay (ie, "cold" CED). However, published CED practices vary widely, 2,9,13,14 and most recommendations come from the simulation and resuscitation literatures. 2,4,6,[15][16][17][18][19] There are few studies in which researchers have examined CED across inpatient settings, including hospital wards. ...
... However, published CED practices vary widely, 2,9,13,14 and most recommendations come from the simulation and resuscitation literatures. 2,4,6,[15][16][17][18][19] There are few studies in which researchers have examined CED across inpatient settings, including hospital wards. [20][21][22][23] Moreover, although CED may be considered important and useful, 13,15,21,22,24 the subjective experience of CED participants is relatively unknown (although it may impact their practice). ...
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.
... 19 Debriefing scripts support facilitators by providing some (or all) of the following content pieces: a written plan for the debriefing, which may include topics for discussion, suggested words or phrases to guide discussion, and/or an overarching framework to structure the debriefing. [20][21][22][23][24][25] While their use has gained traction in both educational 20,21 and clinical settings, [22][23][24] the benefits of debriefing scripts to support resuscitation instructors have not been clearly summarized. Clarifying the value of debriefing scripts for resuscitation training will assist programs in supporting their instructors with this important resource. ...
... 19 Debriefing scripts support facilitators by providing some (or all) of the following content pieces: a written plan for the debriefing, which may include topics for discussion, suggested words or phrases to guide discussion, and/or an overarching framework to structure the debriefing. [20][21][22][23][24][25] While their use has gained traction in both educational 20,21 and clinical settings, [22][23][24] the benefits of debriefing scripts to support resuscitation instructors have not been clearly summarized. Clarifying the value of debriefing scripts for resuscitation training will assist programs in supporting their instructors with this important resource. ...
Objectives
To evaluate the effectiveness of scripted debriefing relative to no use of script during debriefing in resuscitation training.
Methods
This scoping review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and based on the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) extension for scoping review. MEDLINE, EMBASE, and SCOPUS were searched from inception to January 2024. We included all published studies comparing scripted debriefing vs non-scripted debriefing evaluating patient outcomes, behaviour change of learners, learning outcomes for learners and cognitive load and teaching quality for instructors.
Results
Our initial literature search identified 1238 citations. After removing 552 duplicates, reviewing the titles and abstracts of the remaining 686 articles yielded 11 for full-text review. Of these, six articles were selected for inclusion in the final analysis. The six studies described debriefing scripts varying in content, framework, scripted language and the integration of objective data. Scripted debriefing improved CPR performance, team leadership skills and knowledge acquisition, but showed no difference in teamwork performance compared to non-scripted debriefing. Scripted debriefing also improved debriefing quality and decreased cognitive load of the instructor during resuscitation training.
Conclusion
The use of a debriefing script during resuscitation education can improve CPR performance, team leader performance, knowledge acquisition and reduce the debriefer’s cognitive load. Future research should explore how debriefing scripts can be designed to optimize learning outcomes.
... In clinical practice, systematic debriefing following a critical situation remains inconsistent [51,55,[62][63][64], having been observed in only 26-49% of relevant cases, and its implementation may be considered as an essential step, which could be facilitated by healthcare establishments [65], following indispensable debriefing training [43,66]. In this respect, practical tools are available, such as PEARLS for simulation [67], as well as specific tools for clinical practice following, for example, paediatric cardiac arrest [66], or the non-specific ''crisis'' tools of the HAS [46]. ...
... In clinical practice, systematic debriefing following a critical situation remains inconsistent [51,55,[62][63][64], having been observed in only 26-49% of relevant cases, and its implementation may be considered as an essential step, which could be facilitated by healthcare establishments [65], following indispensable debriefing training [43,66]. In this respect, practical tools are available, such as PEARLS for simulation [67], as well as specific tools for clinical practice following, for example, paediatric cardiac arrest [66], or the non-specific ''crisis'' tools of the HAS [46]. ...
Objective:
To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care.
Design:
A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit 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/ organisation, 3/ working environment and 4/ training. 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 application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions.
Conclusion:
Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.
... 17 Debriefing tools have been used to support facilitation of debriefing conversations by providing structure, sample questions or phrases, and suggested topics for discussion. [22][23][24][25][26][27] While their use has gained traction in both educational 22,23 and clinical settings, [24][25][26] the true benefit of debriefing tools supplemented by objective performance data from cardiac arrest events is uncertain. An understanding of the impact of data-informed debriefing with a debriefing tool will assist programs in implementing clinical debriefings that directly impact performance during cardiac arrest. ...
... 17 Debriefing tools have been used to support facilitation of debriefing conversations by providing structure, sample questions or phrases, and suggested topics for discussion. [22][23][24][25][26][27] While their use has gained traction in both educational 22,23 and clinical settings, [24][25][26] the true benefit of debriefing tools supplemented by objective performance data from cardiac arrest events is uncertain. An understanding of the impact of data-informed debriefing with a debriefing tool will assist programs in implementing clinical debriefings that directly impact performance during cardiac arrest. ...
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.
... 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.
... [29][30][31] The content was derived from our literature review. 27,[32][33][34][35][36][37][38] We revised the items using an iterative process with a panel of local and national experts including an expert in clinical debriefing (PM), an expert in debriefing after simulation (MBF), and an expert in educational checklist development methodology (KH). To ensure that the measurable leadership behaviors reflected the experiences of other ED staff and to further strengthen content validity, we gathered feedback from experienced PEM advanced practice providers and a nurse educator in our ED (AG, KSS, DD). ...
Objectives
Clinical event debriefing (CED) improves healthcare team performance and patient outcomes. Most pediatric emergency medicine (PEM) physicians do not receive formal training in leading CED. Our objectives were to develop a CED curriculum and evaluate its effect on performance, knowledge, comfort, and clinical practice.
Methods
This was a single group pre-post-retention study. We developed a hybrid curriculum with simulation, an interactive module, and individual feedback. We invited faculty and fellows from the PEM division of our hospital to participate. During an in-person training day, participants led standardized clinical simulation scenarios followed by simulated CED with immediate feedback on their leadership performance. They watched an interactive module between scenarios. Participants returned for a retention assessment 2–6 months later with a third simulation and debrief. Participants completed surveys measuring attitudes, experiences, and knowledge. Participants also evaluated the curriculum.
The primary outcome was CED leadership performance using a novel 21-item tool that we developed, the Debrief Leadership Tool for Assessment (DELTA). A blinded, trained rater measured performance with DELTA. Secondary outcomes included changes in knowledge and comfort and changes in clinical practice.
Results
Twenty-seven participants enrolled and completed all parts of the curriculum and assessments. Debrief leadership performance improved by a mean of 3.7 points on DELTA pre-training to post-training (95% confidence interval = 2.7, 4.6, P < 0.01) and by 1.4 points from pre-training to retention (95% confidence interval = 0.1, 2.8, P = 0.03). Knowledge and comfort also significantly improved from pre-training to post-training and were sustained at retention. Most (67%) participants changed their clinical practice of CED after completing the curriculum. All participants would recommend the training to other PEM physicians.
Conclusions
A hybrid simulation-based curriculum in leading CED for PEM physicians was associated with improvement in CED leadership performance, knowledge, and comfort. PEM physicians incorporated training into their clinical practice.
... Relying solely on clinician memory during debriefs poses risks, including recall errors (25). Providing a dedicated computer during C&C sessions facilitated access to more accurate data and encouraged active learning, allowing clinicians to explore relevant content in real-time. ...
... Poročilo se konča s povzetkom tega, kar se bo storilo drugače v prihodnosti in opredelitvijo vprašanj, ki zahtevajo nadaljnje spremljanje. S postavljanjem odprtih vprašanj in omejevanjem lastnih navedb moderator usmerja razpravo (7). ...
... Poročilo se konča s povzetkom tega, kar se bo storilo drugače v prihodnosti in opredelitvijo vprašanj, ki zahtevajo nadaljnje spremljanje. S postavljanjem odprtih vprašanj in omejevanjem lastnih navedb moderator usmerja razpravo (7). ...
... Diese betrafen nicht nur die Stationstätigkeit, sondern auch die Mitarbeit im Rahmen der Projektgruppe. Ein weiterer möglicher Einflussfaktor lag in der Pandemie durch die Coronavirus-Krankheit-2019 (COVID-19) und im damit verbundenen gestiegenen Arbeitsaufkommen.Die Evaluationsergebnisse bestätigen außerdem die in der Literatur beschriebene Dauer eines Debriefings von maximal 10 min[8,17] und zeigen damit, dass eine kurze Nachbesprechung gelingen kann. Insgesamt ist das Ausfüllen der Debriefingprotokolle vielen Beschäftigten nicht leichtgefallen. ...
In the context of medical care, healthcare professionals are confronted with cardiopulmonary resuscitation, which can have long-term effects on the participants.
The aim was to develop, implement, and evaluate a protocol-supported post-resuscitation talk for practice in the intensive care unit of a university hospital.
Within the evidence-based nursing working group, university-qualified nurses performed a systematic literature search in CareLit (hpsmedia, Hungen, Germany), the Cochrane Library (Cochrane, London, England), LIVIVO (Deutsche Zentralbibliothek für Medizin, Cologne, Germany), and PubMed/MEDLINE (U.S. National Library of Medicine, Bethesda, MD, USA) as well as using the snowball principle. Based on the results, the post-resuscitation talk and a debriefing protocol were developed and consented in a multiprofessional team. Additionally, a questionnaire to analyze the current situation (t0) and evaluate the implementation (t1) was developed.
Implementation of the post-resuscitation talk was conducted from August 2021. The t0 survey took place from June to July 2021 and for t1 from February to March 2022. In t0, fewer interprofessional reflections were carried out after resuscitations in the category always or frequently (17.5%, n = 7) than in t1 (50.0%, n = 13). The rate of initiated improvement interventions was increased (t0: 24.3%, n = 9 vs. t1: 59.1%, n = 13). The results show promotion of multiprofessional collaboration in t0 and t1, and potential for optimization in the debriefing protocol in t1.
Implementation of a post-resuscitation talk in hospitals is a useful tool for the structured interprofessional follow-up of resuscitation events. The results demonstrated initial positive effects and potential for optimization.
... The debriefing script may improve the facilitator's ability to lead the debrief effectively and may enhance knowledge acquisition [33]. To elaborate, debriefings conducted after cardiac arrest resuscitations have shown associations with enhanced adherence to resuscitation protocols, increased patient survival rates, and improved neurological outcomes [47][48][49][50]. ...
Background
Currently, there are no separate debriefing models for online simulation training, and existing models simply imitate the traditional models used in on-site simulation training (the physical presence of individuals, such as students or trainees, in a simulation center). This involves hands-on, in-person training within a simulated environment to enhance practical skills and knowledge in a controlled setting. This scenario does not fully meet the requirements and capabilities of distance learning.
Objective
To develop a staged defragmented debriefing model as integrated micro-debriefing components inside an online simulation to support the development of clinical decision-making and competencies formation within medical education and offer recommendations to support the use of this debriefing model as a teaching strategy.
Methods
This descriptive study was conducted from August 2020 to September 2023. To build a staged defragmented debriefing model as integrated micro-debriefing components inside an online simulation for competencies formation the traditional debriefing model's components for on-site simulation training, simulation type, and structure, modern concepts of e-learning, and classification of the seriousness of medication errors were used. The main focus of this study was on providing a detailed account of the debriefing components for online simulation training, features, and implementation of this new teaching model. A total of 38 participants, healthcare professionals, were recruited for this study. The participants were randomly assigned to two groups: one experiencing the staged defragmented debriefing model (n = 20) and the other control group, which received traditional debriefing following simulation training (n = 18).
Results
The results allowed us to successfully develop a staged defragmented debriefing model inside the simulation that integrates micro-debriefing components located at different points of the simulation scenarios. This teaching approach was successfully implemented in online clinical case scenarios in the “ClinCaseQuest" Simulation Training Platform for continuous medical education. Additionally, an internal validation experiment comparing the effectiveness of the staged defragmented debriefing model with the traditional debriefing method demonstrated superior learning outcomes and participant satisfaction in the staged debriefing group.
Conclusions
The staged defragmented debriefing model, when integrated into online simulations, represents a promising strategy for advancing clinical decision-making skills and competencies formation in medical education. Implementation of this debriefing model as a teaching strategy holds promise for enhancing learning outcomes in medical education settings. Further research, validation, and implementation are recommended to maximize the model’s potential impact on medical education and training.
... El tiempo destinado para el debriefing debe estar acorde con los objetivos de aprendizaje, se recomienda que no sea menor a 30 minutos (de Góes & Jackman, 2020; Fey & Jenkins, 2015;Husebø et al., 2013;. Para la cantidad de alumnos en el debriefing se aconseja que deben ser grupos pequeños para facilitar la privacidad y confidencialidad (Fey & Jenkins, 2015;Mullan et al., 2013). ...
Introducción: Las escuelas y facultades de enfermería vienen mejoran sus currículos para entregar a la sociedad profesionales acordes a las nuevas necesidades, como parte de la mejora se utiliza la simulación clínica y el debriefing que fomentan la reflexión de la práctica y el aprendizaje significativo.
Objetivos: Identificar los fundamentos metodológicos utilizados en el debriefing que fortalecen el logro de competencias en los estudiantes de enfermería.
Metodología: Revisión sistemática de la literatura entre noviembre y diciembre del 2021 considerando artículos de texto completo, en español, inglés y portugués; y entre el 2011 y 2021, se buscó en ScienceDirect, SciELO, Pubmed, ProQuest y EBSCO; mediante los operadores booleanos “AND” y “OR”. Se utilizó el gestor bibliográfico Mendeley para almacenar y procesar los artículos aplicándose la metodología PRISMA.
Resultados: De los 118 artículos, 31.3% son de MEDLINE/Pubmed, 26.3% de ScienceDirect, 19.5% de ProQuest, 11.9% de SciELO y 11.0% de EBSCO.
Conclusiones: Durante el debriefing se realiza una reflexión de la práctica entre el docente y los estudiantes, logrando identificar los modelos mentales de los estudiantes y haciendo una comparación entre el resultado obtenido y el esperado, para modificar modelos mentales erróneos favoreciendo el logro de competencias de los estudiantes en futuras atenciones.
... [8][9][10] Many obstacles relating to resourcing, education and culture have been identified that prevent the implementation of debriefing into clinical practice. [11][12][13][14][15][16][17][18][19][20][21][22][23][24] A lack of consistency in the conceptualisation and terminology describing CD also impact implementation. It is described that variations in CD and its related terms have influenced its conceptualisation, leading to significant inconsistencies in the delivery and structure in practice. ...
Introduction
Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.
Methods
Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.
Results
Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.
Conclusions
The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.
... Debriefers focus on asking questions, such as: What went well (the plus question)? What would you do differently (the delta question) (Eppich & Cheng, 2015;Mullan, et al., 2013;Zinns et al., 2017)? A third question can preface the plus-delta approach to debriefings: How do you feel? ...
Debriefing may be the most important factor for learning in simulations. This exploratory case study investigated a modified Plus-Delta approach to debriefings following mixed reality simulation-based learning. The findings suggested that educational leadership students who encountered debriefings from simulations developed leadership skills and dispositions and perceived that those acquired skills and dispositions would transfer to leadership positions currently or in the future. Implications and recommendations are provided.
... Due to the frequent exposure to complex and critical situations, CDs have primarily been introduced and practiced in emergency departments (EDs). Indeed, there is extensive evidence of the benefits of these debriefings in the ED: improvement of knowledge and clinical performance (6)(7)(8)(9), communication, team dynamics, and efficiency (9)(10)(11)(12), thus Paquay et al. . ...
The COVID-19 crisis impacted emergency departments (ED) unexpectedly and exposed teams to major issues within a constantly changing environment. We implemented post-shift clinical debriefings (CDs) from the beginning of the crisis to cope with adaptability needs. As the crisis diminished, clinicians voiced a desire to maintain the post-shift CD program, but it had to be reshaped to succeed over the long term. A strategic committee, which included physician and nurse leadership and engaged front-line staff, designed and oversaw the implementation of CD. The CD structure was brief and followed a debriefing with a good judgment format. The aim of our program was to discover and integrate an organizational learning strategy to promote patient safety, clinicians' wellbeing, and engagement with the post-shift CD as the centerpiece. In this article, we describe how post-shift CD process was performed, lessons learned from its integration into our ED strategy to ensure value and sustainability and suggestions for adapting this process at other institutions. This novel application of debriefing was well received by staff and resulted in discovering multiple areas for improvement ranging from staff interpersonal interactions and team building to hospital wider quality improvement initiatives such as patient throughput.
... 7 Furthermore, there is a strong belief in the positive future consequences for those involved in the debriefing process, either through the improvement of technical skills or through the confidence to connect with similar situations in the future. 28,29 Despite that, there is an apparent lack of adherence to the debriefing process, which points to an implementation issue within the organizations. Some described strategies to improve compliance with debriefing include central hospital-wide departmental support, efficient documentation methods, and highly motivated groups of professionals involved in implementing a debriefing tool as part of their quality improvement project. ...
Unlabelled:
Debriefing is an essential procedure for identifying medical errors, improving communication, reviewing team performance, and providing emotional support after a critical event. This study aimed to describe the current practice and limitations of debriefing and gauge opinions on the best timing, effectiveness, need for training, use of established format, and expected goals of debriefing among Portuguese anesthesiologists.
Methods:
We performed a national cross-sectional online survey exploring the practice of anesthesiologists' debriefing practice after critical events in Portuguese hospitals. The questionnaire was distributed using a snowball sampling technique from July to September 2021. Data were descriptively and comparatively analyzed.
Results:
We had replies from 186 anesthesiologists (11.3% of the Portuguese pool). Acute respiratory event was the most reported type of critical event (96%). Debriefing occurred rarely or never in 53% of cases, 59% of respondents needed more training in debriefing, and only 4% reported having specific tools in their institutions to carry it out. There was no statistical association between having a debriefing protocol and the occurrence of critical events (P=.474) or having trained personnel (P=.95). The existence of protocols was associated with lower frequencies of debriefing (P=.017).
Conclusions:
Portuguese anesthesiologists know that debriefing is an essential process that increases patient safety, but among those surveyed, there is a need for an adequate debriefing culture or practice.
Trial registration:
Research registry 7741 (https://www.researchregistry.com/browse-the-registry#home).
... 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.
This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.
This chapter explores the means by which practicing intensivists address poor outcomes after they have occurred. That is, advice around managing the aftermath of adverse events, mistakes, and deaths. Key to this process is the need to balance the clinical need for a close examination of the events with the potential emotional distress such processes can induce among those that were present. The risk management process is discussed as well as the importance of an open, honest approach when speaking with affected family members. The chapter concludes with a review of debriefing approaches and the value of professional mental health support for those involved in such events.KeywordsRiskHarmErrorResilienceCopingDebriefingRoot cause analysis
Objective:
Hot debriefings are communications among team members occurring shortly after an event. They have been shown to improve team performance and communication. Best practice guidelines encourage hot debriefings, but these are often not routinely performed. We aim to describe the development and implementation of a multidisciplinary hot debriefing process in our pediatric emergency department (ED), and its impact on hot debriefing completion and provider perceptions.
Methods:
An internal tool and protocol for hot debriefings were developed by integrating responses from a survey of those who work in the ED at our institution and previously published debriefing tools. Charge nurses and pediatric emergency medicine physicians were trained to lead hot debriefings. Surveys on the perception of hot debriefings were administered before and 6 months postimplementation.Twelve-month baseline data were established by asking physicians who cared for patients who died in the ED or within 48 hours of admission to recall debrief completion. Debriefs were then prospectively tracked for 6 months postimplementation.
Results:
Debrief completion for patient deaths in the ED or within 48 hours of admission increased from 23% (5/22) to 75% (12/16) (P < 0.001). When assessing just those deaths within the ED, this number increased from 31% (5/16) to 85% (11/13) (P < 0.001).There were 98 responses to a baseline survey (response rate, 60.5%). Most who were surveyed felt that debriefs rarely occurred, preferred hot debriefings to cold debriefings, and felt that more hot debriefings should occur. Perceived barriers included lack of time, interest, protocol, trained facilitators, departmental support, and inability to gather the team.There were 88 responses to a postintervention survey (response rate, 56.8%), 50 of which had participated in a debrief and were included in analysis. Those surveyed felt that debriefs occurred more often and were more often valuable. Most perceived that barriers were significantly reduced. Most respondents felt that hot debriefs helped address systems issues and improved performance.
Conclusions:
Implementation of a protocol for physician or charge nurse-led hot debriefings in our pediatric ED resulted in increased completion, perceived barrier reduction, and a uniform approach to address identified issues. Pediatric EDs should consider adoption of a hot debriefing protocol given these benefits.
Aim:
This study evaluated the impact of a single dose of training in Debriefing for Meaningful Learning (DML) on learner knowledge outcomes and time spent in debriefing.
Background:
Regulatory bodies recommend that faculty who debrief receive training and competence assessment to ensure positive student learning outcomes, yet there is little literature describing the training needed. There is also little understanding of the impact of a single training on the length of debriefing, debriefer skill, and learner outcomes.
Method:
Following training, debriefers submitted a recorded debriefing for assessment by experts; their learners completed knowledge assessment tests at three time points.
Results:
Longer debriefing time led to higher DML Evaluation Scale scores. Learner knowledge scores improved and later decayed.
Conclusion:
The results of this study contribute to the evidence about the importance of training to debrief well, the impact of training on the length of debriefing time, and subsequent learner outcomes.
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.
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.)
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.
This Policy Statement was reaffirmed June 2011, July 2014, and August 2018
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.
Paediatric Research in Emergency Departments International Collaborative (PREDICT), Debriefing critical incidents in the paedi-atric emergency department: current practice and perceived needs in Australia and New Zealand
- Theophilos T J Magyar
- Fe
Theophilos T, Magyar J, Babl FE. Paediatric Research in Emergency Departments International Collaborative (PREDICT), Debriefing critical incidents in the paedi-atric emergency department: current practice and perceived needs in Australia and New Zealand. Emerg Med Australas 2009;21:479–83.
Clinical Simulation: MW. Operations, engineering, and management
- R Kyle
Kyle R, Clinical Simulation: MW. Operations, engineering, and management.
Burlington, MA, USA: Academic Press; 2007.
Texas Health and Safety Code Title 2
Texas Health and Safety Code Title 2. Health Subtitle H. Public Health Provisions,
Ch.161.; 2012.
Immediate post-event debriefing improves multiple aspects of response to codes and increases staff satisfaction: Agency for Healthcare Research and Quality -Service Delivery Innovation Profile
- F Harris
Harris F. Immediate post-event debriefing improves multiple aspects of
response to codes and increases staff satisfaction: Agency for Healthcare
Research and Quality -Service Delivery Innovation Profile. <http://innovations.
ahrq.gov/content.aspx?id=3053>; 2011 [accessed 13.09.12].