Article

Implementation of an In Situ Qualitative Debriefing Tool for Resuscitations

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

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.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Notably, the literature that suggests these adverse outcomes included studies which used CISD outside the model's intended framework, such that debrie ng occurred one-on-one with patients instead of in a group setting with frontline providers. (16,17) Newer methods of post-event debrie ng, such as the INFO and DISCERN models, (18,19) are structured to avoid many of the perceived pitfalls of CISD through their more immediate timing and provider-implemented style. (20) In this paper, the term "debrie ng" will be used to indicate a form of peer support, discussion-based stress intervention. ...
... (25) Pediatric and adult resuscitations are common pre-selected clinical events which should initiate a debrie ng. (14,19,24,26) Clinical events previously recognized as distressing for staff or cited as critical incidents in the literature include death of a patient, multi-trauma, and death of young patients. (1,19,27) To cope with emotionally challenging patient cases, nurses have previously reported reliance upon peer support and physicians have voiced a preference for a more formal support structure. ...
... (14,19,24,26) Clinical events previously recognized as distressing for staff or cited as critical incidents in the literature include death of a patient, multi-trauma, and death of young patients. (1,19,27) To cope with emotionally challenging patient cases, nurses have previously reported reliance upon peer support and physicians have voiced a preference for a more formal support structure. (22,23,26) The extent of the pandemic will increase the number of patient deaths experienced by providers in high prevalence regions, further challenging provider well-being. ...
Preprint
Full-text available
Background: Emergency department personnel routinely bear witness to traumatic experiences and critical incidents that can affect their own well-being. Peer support through debriefing has demonstrated positive impacts on clinicians’ well-being following critical incidents. This study explored community hospital emergency department staff’s perceptions of critical incidents, assessed openness to debriefing and measured baseline well-being. Our analysis provides a baseline of provider well-being immediately prior to the local onset of COVID-19. The potential need for additional resources to support frontline providers during the pandemic can be evaluated. Method: We conducted a cross-sectional study for 4-weeks prior to the first COVID-19 case in Connecticut using a survey offered to an interprofessional group of emergency department clinical staff. The main outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Professional Quality of Life (ProQOL) scale. Pearson’s chi-square test was used to identify significant differences in perceptions of critical incidents and debriefings between professional categories. One-way ANOVA and Tukey’s test were used to analyze significant differences in well-being between professional categories. Results: Thirty-nine clinical personnel from St. Vincent’s Emergency Department responded to the survey. Events frequently selected as critical incidents were caring for critically ill children (89.7%), mass casualty events (84.6%), and death of a patient (69.2%). Critical incidents were commonly reported (81.6%) as occurring once per week. Additionally, 76.2% of participants reported wanting to discuss a critical incident with their team. Across all respondents, 45.7% scored borderline or abnormal for anxiety, 55.9% scored moderate for burnout, and 55.8% scored moderate to high for secondary traumatic stress. Conclusions: At baseline, providers reported caring for critically ill children, mass casualty events, and death of a patient as critical incidents, which typically occurred once per week. Death of a patient occurs at increased frequency during the protracted mass casualty experience of COVID-19 and threatens provider well-being. Receptiveness to post-event debriefing is high but the method is still underutilized. With nearly half of staff scoring borderline or abnormal for anxiety, burnout, and secondary traumatic stress at baseline, peer support measures should be implemented to protect frontline providers’ well-being during and after the pandemic.
... Debriefing is a method to facilitate discussion of actions, guide reflection and transfer learning behaviors into clinical practice [8][9][10]. The American Heart Association (AHA) [11] and European Resuscitation Council (ERC) [12] recommend the use of debriefing to enhance clinical outcomes. ...
... To record and identify the context of the shift, trained facilitators would document shift demographics and reactions of clinical team members. Team reflection was facilitated by encouraging episodes of self-reflection via the "plus/delta" analysis method [10]. This method was selected primarily because the facilitator was external to the clinical team and was not present on shift to observe the activity. ...
... Based on the debriefing program objectives and previously reported best practices [9,25], all team members actively involved in the management of COVID-19 patients in the ED should be invited to participate in the debriefing. In previous debriefing programs, a clinical team member, such as the physician team leader [10,17,26,27] or the charge nurse [28] could serve as facilitator of the debriefing, but occasionally such a leader may prevent teammates from talking openly or may cause a reporting bias [9]. Given this concern and the local preferences of frontline clinicians, a debriefer with healthcare simulation experience from outside the clinical team serves in the role of facilitator for each debriefing. ...
Article
Full-text available
Background: Multiple guidelines recommend debriefing after clinical events in the emergency department (ED) to improve performance, but their implementation has been limited. We aimed to start a clinical debriefing program to identify opportunities to address teamwork and patient safety during the COVID-19 pandemic. Methods: We reviewed existing literature on best-practice guidelines to answer key clinical debriefing program design questions. An end-of-shift huddle format for the debriefs allowed multiple cases of suspected or confirmed COVID-19 illness to be discussed in the same session, promoting situational awareness and team learning. A novel ED-based clinical debriefing tool was implemented and titled Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE). A facilitator experienced in simulation debriefings would facilitate a short (10–25 min) discussion of the relevant cases by following a scripted series of stages for debriefing. Data on the number of debriefing opportunities, frequency of utilization of debriefing, debriefing location, and professional background of the facilitator were analyzed. Results: During the study period, the ED treated 3386 suspected or confirmed COVID-19 cases, with 11 deaths and 77 ICU admissions. Of the 187 debriefing opportunities in the first 8-week period, 163 (87.2%) were performed. Of the 24 debriefings not performed, 21 (87.5%) of these were during the four first weeks (21/24; 87.5%). Clinical debriefings had a median duration of 10 min (IQR 7–13). They were mostly facilitated by a nurse (85.9%) and mainly performed remotely (89.8%). Conclusion: Debriefing with DISCOVER-PHASE during the COVID-19 pandemic were performed often, were relatively brief, and were most often led remotely by a nurse facilitator. Future research should describe the clinical and organizational impact of this DISCOVER-PHASE.
... Thus, many spaces are not designated or designed for debriefing, which in turn may lead to difficulty finding a suitable location without prior consideration. On the one hand, a CD location close to where the event(s) took place may ease the team's recall of the environmental challenges such as ambient noise, physical obstructions, overcrowding of space, or broken equipment (Small 2007;Mullan et al. 2013). On the other hand, moving to a remote area for debriefing may be more practicable in some instances. ...
... Whilst universal participation is encouraged, debriefing should be non-mandatory in the first instance, because compulsory attendance may cause stress in some participants (Mancini and Bonanno 2006). Furthermore, a key component of programme sustainability appears to lie in a focus on team performance (Mullan et al. 2013;Kessler et al. 2015) rather than individual performance (Rose and Cheng 2018). ...
... On the one hand, most contemporary CD guidelines advise against creating formal documentation of the debriefing for inclusion in the patient record in view of the risk of future subpoena (Mullan et al. 2013). Seek local risk management expertise to ensure concerns surrounding confidentiality and non-discoverability are suitably addressed (Sawyer et al. 2016). ...
Article
Contemporary clinical practice places a high demand on healthcare workforces due to complexity and rapid evolution of guidelines. We need embedded workplace practices such as clinical debriefing (CD) to support everyday learning and patient care. Debriefing, defined as a 'guided reflective learning conversation', is most often undertaken in small groups following simulation-based experiences. However, emerging evidence suggests that debriefing may also enhance learning in clinical environments where facilitators need to simultaneously balance psychological safety, learning goals and emotional well-being. This twelve tips article summarises international experience collated at the recent Association for Medical Education in Europe (AMEE) debriefing symposium. These tips encompass the benefits of CD, as well as suggested approach to facilitation. Successful CD programmes are frequently team focussed, interdisciplinary, implemented in stages and use a clear structure.
... Notably, the literature that suggests these adverse outcomes included studies which used CISD outside the model's intended framework, such that debriefing occurred one-on-one with patients instead of in a group setting with frontline providers [16,17]. Newer methods of post-event debriefing, such as the INFO and DISC ERN models, [18,19] are structured to avoid many of the perceived pitfalls of CISD through their more immediate timing and provider-implemented style [20]. In this paper, the term "debriefing" will be used to indicate a form of peer support, discussion-based stress intervention. ...
... A critical incident has been defined by Magyar et al as, "a selfdefined traumatic event that causes individuals to experience such strong emotional responses that usual coping mechanisms are ineffective" [25]. Pediatric and adult resuscitations are common pre-selected clinical events which should initiate a debriefing [14,19,24,26]. Clinical events previously recognized as distressing for staff or cited as critical incidents in the literature include death of a patient, multi-trauma, and death of young patients [1,19,27]. ...
... Pediatric and adult resuscitations are common pre-selected clinical events which should initiate a debriefing [14,19,24,26]. Clinical events previously recognized as distressing for staff or cited as critical incidents in the literature include death of a patient, multi-trauma, and death of young patients [1,19,27]. To cope with emotionally challenging patient cases, nurses have previously reported reliance upon peer support and physicians have voiced a preference for a more formal support structure [22,23,26]. ...
Article
Full-text available
Background Emergency department personnel routinely bear witness to traumatic experiences and critical incidents that can affect their own well-being. Peer support through debriefing has demonstrated positive impacts on clinicians’ well-being following critical incidents. This study explored community hospital emergency department staff’s perceptions of critical incidents, assessed openness to debriefing and measured baseline well-being. Our analysis provides a baseline of provider well-being immediately prior to the local onset of COVID-19. The potential need for additional resources to support frontline providers during the pandemic can be evaluated. Method We conducted a cross-sectional study for 4-weeks prior to the first COVID-19 case in Connecticut using a survey offered to an interprofessional group of emergency department clinical staff. The main outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Professional Quality of Life (ProQOL) scale. Pearson’s chi-square test was used to identify significant differences in perceptions of critical incidents and debriefings between professional categories. One-way ANOVA and Tukey’s test were used to analyze significant differences in well-being between professional categories. Results Thirty-nine clinical personnel from St. Vincent’s Emergency Department responded to the survey. Events frequently selected as critical incidents were caring for critically ill children (89.7%), mass casualty events (84.6%), and death of a patient (69.2%). Critical incidents were commonly reported (81.6%) as occurring once per week. Additionally, 76.2% of participants reported wanting to discuss a critical incident with their team. Across all respondents, 45.7% scored borderline or abnormal for anxiety, 55.9% scored moderate for burnout, and 55.8% scored moderate to high for secondary traumatic stress. Conclusions At baseline, providers reported caring for critically ill children, mass casualty events, and death of a patient as critical incidents, which typically occurred once per week. Death of a patient occurs at increased frequency during the protracted mass casualty experience of COVID-19 and threatens provider well-being. Receptiveness to post-event debriefing is high but the method is still underutilized. With nearly half of staff scoring borderline or abnormal for anxiety, burnout, and secondary traumatic stress at baseline, peer support measures should be implemented to protect frontline providers’ well-being during and after the pandemic.
... Notably, the literature that suggests these adverse outcomes included studies which used CISD outside the model's intended framework, such that debrie ng occurred one-on-one with patients instead of in a group setting with frontline providers. (16,17) Newer methods of post-event debrie ng, such as the INFO and DISCERN models, (18,19) are structured to avoid many of the perceived pitfalls of CISD through their more immediate timing and provider-implemented style. (20) In this paper, the term "debrie ng" will be used to indicate a form of peer support, discussion-based stress intervention. ...
... (25) Pediatric and adult resuscitations are common preselected clinical events which should initiate a debrie ng. (14,19,24,26) Clinical events previously recognized as distressing for staff or cited as critical incidents in the literature include death of a patient, multi-trauma, and death of young patients. (1,19,27) To cope with emotionally challenging patient cases, nurses have previously reported reliance upon peer support and physicians have voiced a preference for a more formal support structure. ...
... (14,19,24,26) Clinical events previously recognized as distressing for staff or cited as critical incidents in the literature include death of a patient, multi-trauma, and death of young patients. (1,19,27) To cope with emotionally challenging patient cases, nurses have previously reported reliance upon peer support and physicians have voiced a preference for a more formal support structure. (22,23,26) The aim of this study is to describe the well-being of community hospital emergency department clinical staff immediately prior to the local onset of COVID-19 and identify their perceptions surrounding critical incidents and post-event, discussion-based interventions. ...
Preprint
Full-text available
Background: Emergency department personnel routinely bear witness to traumatic experiences and critical incidents that can affect their own well-being. Peer support through debriefing has demonstrated positive impacts on clinicians’ well-being following critical incidents. This study explored community hospital emergency department staff’s perceptions of critical incidents, assessed openness to debriefing and measured baseline well-being. Our analysis provides a baseline of provider well-being immediately prior to the local onset of COVID-19. The potential need for additional resources to support frontline providers during the pandemic can be evaluated. Method: We conducted a cross-sectional study for 4-weeks prior to the first COVID-19 case in Connecticut using a survey offered to an interprofessional group of emergency department clinical staff. The main outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Professional Quality of Life (ProQOL) scale. Pearson’s chi-square test was used to identify significant differences in perceptions of critical incidents and debriefings between professional categories. One-way ANOVA and Tukey’s test were used to analyze significant differences in well-being between professional categories. Results: Thirty-nine clinical personnel from St. Vincent’s Emergency Department responded to the survey. Events frequently selected as critical incidents were caring for critically ill children (89.7%), mass casualty events (84.6%), and death of a patient (69.2%). Critical incidents were commonly reported (81.6%) as occurring once per week. Additionally, 76.2% of participants reported wanting to discuss a critical incident with their team. Across all respondents, 45.7% scored borderline or abnormal for anxiety, 55.9% scored moderate for burnout, and 55.8% scored moderate to high for secondary traumatic stress. Conclusions: At baseline, providers reported caring for critically ill children, mass casualty events, and death of a patient as critical incidents, which typically occurred once per week. Death of a patient occurs at increased frequency during the protracted mass casualty experience of COVID-19 and threatens provider well-being. Receptiveness to post-event debriefing is high but the method is still underutilized. With nearly half of staff scoring borderline or abnormal for anxiety, burnout, and secondary traumatic stress at baseline, peer support measures should be implemented to protect frontline providers’ well-being during and after the pandemic.
... 58 In a study on the implementation of a debriefing tool for emergent resuscitations in a pediatric ED, there was a 26% debriefing rate after the critical events of interest (cardiopulmonary resuscitation, intubation, and/or defibrillation), and "too many urgent patient care issues" was identified as a theme in cases not debriefed. 57 In a survey of resuscitation training officers (physicians [house officers (including in anesthesia) and registrars], nurses, and other team members responding to in-hospital cardiac arrest) across the United Kingdom, less than 8% of respondents said they completed a formal debrief after a cardiac arrest. The reasons for this were again unclear, although the majority of respondents noted that debrief sessions were either offered but not taken up, or were very informal, often limited to a few members of team. ...
... 17 Data from Refs. 17,18,[57][58][59] Real-Time Debriefing After Critical Events this process, there were residents who were self-negotiating their perceived reputation, affective response, and extent to which they internally felt culpable for what had happened. One resident being interviewed after a critical event pondered "if things would have gone differently" if they themselves had been better prepared. ...
... Several of these strategies have also been associated with successful implementation of other patient safety interventions, including tools for debriefing. 23,24,57 The essential role of hospital leaders and resources was emphasized in a review by Salas and colleagues 27 on a set of evidence-based best practices and tips for debriefing medical teams. ...
Article
Debriefing after perioperative crises (eg, cardiac arrest, massive hemorrhage) is a well-described practice that can provide benefits to individuals, teams, and health systems. Debriefing has also been embraced by high-stakes industries outside of health care. Yet, in studies of actual clinical practice, there are many critical events that do not get debriefed. This article explores the gap that exists between principle and reality and the factors and strategies to offer opportunities to reflect on actual critical events, when indicated, across the increasing scope of environments where anesthesia care is provided.
... Though this begs the questions: what constitutes a "good" debriefing, how does an individual debriefer achieve this, and how can it be scaled across an organization? While there are faculty development programs available [16,17], there is no national standard for faculty training in medical simulation or debriefing, despite ample literature supporting specific debriefing best practices [8][9][10][11][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]. ...
... PEARLS scripting improves model accessibility for those debriefers still developing their debriefing skills [18]. PEARLS circumvents some limitations of other debriefing models, including the prioritization of expediency and a requirement for high levels of experience for successful application [20,[23][24][25]. The PEARLS model presents a sequence of four stages: (1) reactions, (2) description, (3) analysis, and (4) summary [18]. ...
... These stages and their associated sample phrases assist debriefers in setting the stage for the debriefing, organizing the debriefing, and helping debriefers pose questions [18]. The PEARLS approach combines the debriefing strategies of learner self-assessment [20,24,26], facilitated reflection and understanding [27][28][29], directed performance feedback [30,31], and focused teaching [28,32]. PEARLS contains these blended strategies within a consolidated model [18]. ...
Article
Full-text available
Purpose Debriefing is necessary for effective simulation education. The PEARLS (Promoting Excellence and Reflective Learning in Simulations) is a scripted debriefing model that incorporates debriefing best practices. It was hypothesized that student simulation performance might impact facilitator adherence to the PEARLS debriefing model. There are no published findings on the effect of student performance on debriefer behavior. Methods Third-year medical students participated in a video-recorded, formative simulation to treat a high-fidelity mannequin for an asthma exacerbation. A faculty debriefer trained in the PEARLS model evaluated student performance with a standardized rubric and conducted a recorded debriefing. Debriefing recordings were analyzed for debriefer adherence to the PEARLS model. Debriefers were assigned a debriefing score (DS) from 0 to 13; 13 was perfect adherence to the model. Definitive intervention (DI) for asthma exacerbation was defined as bronchodilator therapy. Critical actions were as follows: a focused history, heart/lung exam, giving oxygen, and giving a bronchodilator. Results Mean DS for the debriefers of students who provided DI was 8.57; 9.14 for those students who did not ( P = 0.25). Mean DS for debriefers of students who completed all critical actions was 8.68; 8.52 for those students who did not ( P = 0.62). Analysis of elapsed time to DI showed no relationship between the time DI was provided and DS. Conclusions Student performance had no impact on debriefer performance, suggesting the PEARLS model is an effective aid for debriefers, regardless of learner performance. These findings suggest student performance may not bias facilitators’ ability to conduct quality debriefings.
... Many debriefing methods demand considerable skill, which impedes effective implementation. The plus-delta approach to debriefing has multiple benefits since it is conceptually simple and easy to implement, while promoting learner capacity for selfassessment-a skill vital for safe clinical practice [2,5,[7][8][9][10][11][12]. With plus-delta, facilitators engage learners in a self-assessment of their own performance [12], which in turn provides opportunity for individual and team reflexivity [13,14]. ...
... When applying this approach, facilitators ask learners: "What went well and what would you do differently (or improve) next time?" [7,9,12]; "What did you do well, and what did not go well, and why?" [10]; "What was easy and what was challenging for you?" [5]; or other similar questions. Outside of healthcare, the US Army has adopted a version of this approach through a performance feedback method termed "After Action Review" [16,17]. ...
... Following training, soldiers engage in a facilitated conversation to clarify what aspects of performance met pre-defined standards, and where there was opportunity for improvement [17]. The plus-delta approach, when coupled with feedback and teaching, can be used as the primary conversational strategy in a debriefing [7,[9][10][11] or used more selectively by blending it with other strategies (e.g., focused facilitation) depending on the learning context, amount of time available, and facilitator preferences (e.g., learner vs. instructor-centered debriefing) [12,18]. Ideally, an effective plus-delta generates two lists of behaviors (i.e., things that the learners felt went well, and things that the learners felt could be improved), which then prompts further discussion, reflection, and/or learning during the debriefing. ...
Article
Full-text available
The healthcare simulation field has no shortage of debriefing options. Some demand considerable skill which serves as a barrier to more widespread implementation. The plus-delta approach to debriefing offers the advantages of conceptual simplicity and ease of implementation. Importantly, plus-delta promotes learners’ capacity for a self-assessment, a skill vital for safe clinical practice and yet a notorious deficiency in professional practice. The plus-delta approach confers the benefits of promoting uptake of debriefing in time-limited settings by educators with both fundamental but also advanced skills, and enhancing essential capacity for critical self-assessment informed by objective performance feedback. In this paper, we describe the role of plus-delta in debriefing, provide guidance for incorporating informed learner self-assessment into debriefings, and highlight four opportunities for improving the art of the plus delta: (a) exploring the big picture vs. specific performance issues, (b) choosing between single vs. double-barreled questions, (c) unpacking positive performance, and (d) managing perception mismatches.
... 7 Debriefings have been used by HROs such as aviation 8 and the military 9,10 to learn from events to mitigate future risk. Clinical event debriefing (CED) provides opportunities for teams to review a clinical event, [11][12][13][14] reflect on performance, [11][12][13][14][15] identify safety concerns, [11][12][13][14] and develop performance improvement strategies. 11,12,14 Debriefing has been associated with a 20% to 25% improvement in individual and team performance. ...
... Despite the stated benefits of CEDs, most team members of clinical settings do not debrief frequently. 10,14,15,18 Approximately 50% of surveyed pediatric emergency nurses and physicians estimated that debriefing after resuscitations occurred less than 25% of the time. 14 One of the main barriers to consistent debriefing is the lack of debriefing guidelines and tools. ...
... 14 One of the main barriers to consistent debriefing is the lack of debriefing guidelines and tools. 12,14,15,[18][19][20][21] The resources available to guide this essential practice include an acronym framework, 22 an ED postresuscitation debriefing tool, 15 and debriefing scripts focused on general concepts, 18 simulation scenarios, 23 or trauma resuscitations. 13 Through the researchers' review of the literature, we found no ED-specific debriefing guidelines that have undergone a formalized validation process. ...
Article
Objective: Clinical event debriefing is recommended by the American Heart Association and the European Resuscitation Council, because debriefings improve team performance. The purpose here was to develop and validate tools needed to overcome barriers to debriefing in the emergency department. Method: This quality improvement project was conducted in 4 phases. Phase 1: Current evidence related to debriefing in the emergency department was reviewed and synthesized to inform an iterative process for drafting the debriefing guideline and instrument for documentation. Phase 2: Content Validity Index of the tools was evaluated by obtaining ratings of items' clarity and relevance from 5 national experts in 2 rounds of review. On the basis of experts' feedback, tools were revised, and a Facilitators' Guide was created. Phase 3: The validated debriefing tools were implemented. Phase 4: Debriefing facilitators completed a survey about their experience with using the new tools. Results: The Content Validity Index of 71 debriefing tool items (guideline, instrument, Facilitators' Guide) was 0.93 and 0.96 for clarity and relevance, respectively. Of the 32 debriefings conducted during the first 8 weeks of implementation, 53% described patient safety concerns, and 97% described recommendations to improve performance. Most (94%) facilitators agreed that the guideline clarified debriefing requirements. Conclusion: The use of debriefing tools validated by computation of the Content Validity Index led to the identification of safety threats and recommendations to improve care processes. These tools can be used in ED settings to promote team learning and aid in identifying and resolving safety concerns.
... This is often done through group reflection on the shared experience, which is known as debriefing in the clinical context. 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. ...
... 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. Debriefing was seen as a strategy that leads to rich learning opportunities, whilst recognising the unique, complex and chaotic environment in which practice occurs. ...
Article
Background Patient safety and safety culture are critical for quality healthcare delivery in general and in Emergency Departments (EDs) in particular. The aim of this study is to identify strategies that may contribute to the improvement and maintenance of patient safety culture and which are considered most feasible in the ED environment. Methods A two-step modified Delphi method with 11 experts' panel was performed to establish consensus. A list of potential expert participants with a background in patient safety culture in EDs was compiled through the professional networks of the supervisory team. Snowball sampling was used to identify additional possible participants. The expert panel included key leaders in the emergency medicine community in Queensland, Australia: patient safety experts and researchers, patient safety directors, and healthcare providers in an Australian ED The study ran from September 2018 to December 2018. The tool used in Round 1 in this study was developed through triangulating the outcomes of a review of literature, results from a survey of ED staff and findings from semi-structured interviews with key stakeholders in ED. The results from Round 1 informed the development of the Round 2 tool. The responses from the Delphi Round 1 tool were analysed as both qualitative data and quantitative data. The responses from the Delphi Round 2 tool were treated as quantitative data and analysed with the SPSS software. Consensus was calculated based on more than 80% agreement in collapsed categories 1 and 2 (or 4 and 5) of the five-point Likert scale. Results Only six strategies out of 17 (35%) achieved consensus for both importance and feasibility. These strategies may therefore be considered the most important and feasible key strategies for improving safety culture in EDs. Seven strategies (41.1%) achieved consensus for importance, but not for feasibility and four strategies (23.55%) did not achieve consensus for either importance or feasibility. Conclusions This study offers practical solutions for safety culture improvement in the ED context. Six key strategies were seen as both important and feasible and these grouped into three main themes; leadership through agenda setting, operational management approaches to reinforce the agenda and commitment, and systems and structures to reinforce the agenda and monitor progress.
... One potential way to inform debriefing that circumvents the logistical and ethical challenges is self-reflection of the team. Several frameworks for post-resuscitation debriefing exploit that possibility in that they ask the team to reflect on "what went well" and "what could have gone better", for example [30]. Almost all emergency rooms (ERs) establish the role of a physician team leader in their resuscitation teams. ...
... Because most post-resuscitation debriefing frameworks call upon the physician team leader or the charge nurse to decide whether a debrief is required at all (e.g. [30]), the accuracy of their self-evaluation is of critical importance. ...
Article
Full-text available
Background: Working in ad hoc teams in a health care environment is frequent but a challenging and complex undertaking. One way for teams to refine their teamwork could be through post-resuscitation reflection and debriefing. However, this would require that teams have insight into the quality of their teamwork. This study investigates (1) the accuracy of the self-monitoring of ad hoc resuscitation teams and their leaders relative to external observations of their teamwork and (2) the relationship of team self-monitoring and external observations to objective performance measures. Methods: We conducted a quantitative observational study of real-world ad hoc interprofessional teams responding to a simulated cardiac arrest in an emergency room. Teams consisting of residents, consultants, and nurses were confronted with an unexpected, simulated, standardized cardiac arrest situation. Their teamwork was videotaped to allow for subsequent external evaluation on the team emergency assessment measure (TEAM) checklist. In addition, objective performance measures such as time to defibrillation were collected. All participants completed a demographic questionnaire prior to the simulation and a questionnaire tapping their perceptions of teamwork directly after it. Results: 22 teams consisting of 115 health care professionals showed highly variable performance. All performance measures intercorrelated significantly, with the exception of team leaders' evaluations of teamwork, which were not related to any other measures. Neither team size nor cumulative experience were correlated with any measures, but teams led by younger leaders performed better than those led by older ones. Conclusion: Team members seem to have better insight into their team's teamwork than team leaders. As a practical consequence, the decision to debrief and the debriefing itself after a resuscitation should be informed by team members, not just leaders.
... [10][11][12] Debriefings are categorized by time in relation to the initial event, with "hot" debriefings occurring in the minutes to hours following the event and "cold" debriefings occurring in the days to weeks following an incident. 1,6 Hot debriefing utilizes facilitated participant discussion to reflect on events with the team present for the clinical event. This immediate review, while the event is fresh, is key to provide the opportunity for providers to share their emotional responses, address any questions related to clinical care, while concurrently building a culture of teamwork. ...
... Facilitation and/or cofacilitation was performed by physicians 94% (87/93), nurses 18% (17/93), nurse practitioners 9% (8/93), or other (nonclinicians) 8% (7/93). Attendance varied across sites (profession, number per debriefing [IQR]): physicians (12 [4,20]), nurses (1 [1,6]), respiratory therapists (0 [0, 1]), and administrators (1 [0, 1]). Table 2, Supplemental Digital Content 2, http://links.lww.com/PQ9/A193, ...
Article
Full-text available
Introduction: Clinical event debriefing functions to identify optimal and suboptimal performance to improve future performance. "Cold" debriefing (CD), or debriefing performed more than 1 day after an event, was reported to improve patient survival in a single institution. We sought to describe the frequency and content of CD across multiple pediatric centers. Methods: Mixed-methods, a retrospective review of prospectively collected in-hospital cardiac arrest (IHCA) data, and a supplemental survey of 18 international institutions in the Pediatric Resuscitation Quality (pediRES-Q) collaborative. Data from 283 IHCA events reported between February 2016 and April 2018 were analyzed. We used a Plus/Delta framework to collect debriefing content and performed a qualitative analysis utilizing a modified Team Emergency Assessment Measurement Framework. Univariate and regression models were applied, accounting for clustering by site. Results: CD occurred in 33% (93/283) of IHCA events. Median time to debriefing was 26 days [IQR 11, 41] with a median duration of 60 minutes [20, 60]. Attendance was variable across sites (profession, number per debriefing): physicians 12 [IQR 4, 20], nurses 1 [1, 6], respiratory therapists 0 [0, 1], and administrators 1 [0, 1]. "Plus" comments reported per event were most commonly clinical standards 47% (44/93), cooperation 29% (27/93), and communication 17% (16/93). "Delta" comments were in similar categories: clinical standards 44% (41/93), cooperation 26% (24/93), and communication 14% (13/93). Conclusions: CDs were performed after 33% of cardiac arrests in this multicenter pediatric IHCA collaborative. The majority of plus and delta comments could be categorized as clinical standards, cooperation and communication.
... To this end, the typical content of simulation debriefings are well documented [19,20]. However, the current literature on CD most often reflects the 'need for' debriefing or 'how to facilitate', rather than what is disucssed [4,5,21,22]. This study therefore addresses a gap in the literature by examining the topics and content discussed in clinical event debriefing. ...
... In this study, the CDs (mean length 10.93 min) appeared to foster learning in a typically time constrained Emergency Department environment. These findings are consistent with previous studies of a structured CD where numerous topics were addressed within a ten-minute timeframe [14,22]. ...
Article
Full-text available
Background: Defined as a 'guided reflective learning conversation', 'debriefing' is most often undertaken in small groups following healthcare simulation training. Clinical debriefing (CD) following experiences in the working environment has the potential to enhance learning and improve performance. Methods: Prior to the study, a literature review was completed resulting in a standardised approach to CD that was used for training faculty. A pilot study of CD (n = 10) was then performed to derive a list of discussion topics and optimise the faculty training. The resulting debriefing approach was based on the "S.T.O.P." structure (Summarise the case; Things that went well; Opportunities for improvement; Points of action). A debriefing aid, with suggested scripting, was provided. A subsequent observational study assessed CD within 1-h of clinical events. 'Significantly distressing' or 'violent' events were excluded. Data was collected on participant characteristics, discussion topics, and team recommendations. Study forms were non-identifiable. Subsequent analysis was performed by two investigators using content analysis of the debriefing forms (n = 71). Discussion topics (learning points) were coded using a modified version of the Promoting Excellence and Reflective Learning in Simulation (PEARLS) framework. One month after completion of the study, ED management staff were surveyed for reports of "harm" as the result of CD. Results: During the study period, 71 CDs were recorded with a total of 506 participants. Mean debriefing length was 10.93 min (SD 5.6). Mean attendance was 7.13 (SD 3.3) participants. CD topics discussed were divided into 'plus' (well-done) and 'delta' (need to improve) groupings. 232 plus domains were recorded of which 195 (84.1%) aligned with the PEARLS debriefing framework, suggesting simulation debriefing skills may be translatable to a clinical setting. Topics discussed outside the PEARLS framework included family issues, patient outcome and environmental factors. CD reports led to preventative interventions for equipment problems and to changes in existing protocols. There were no recorded incidents of participant harm resulting from CD. Conclusions: Topics discussed in CD predominantly aligned to those commonly observed in simulation-based medical education. Collective recommendations from CD can be used as evidence for improving existing protocols and models of care.
... To our knowledge, only one qualitative debriefing tool had been published for the ED population when we embarked on this project and that was created specifically for emergency pediatric intubation, cardiopulmonary resuscitation and defibrillation (i.e., a different setting and relatively limited case mix). 15 The aim of this study was to design, test and develop an HDB tool that was quick and easy for any staff member to use and that could be used to facilitate safer patient care, team development and quality improvement in the ED. Our primary outcome measure was staff satisfaction with the HDB tool. ...
... Initially, the focus group worked together to determine the feasibility of developing a bespoke ED HDB tool by formally reviewing existing models from research literature used in other clinical contexts 14,15,17,18 and identifying potential benefits and barriers to performing HDB in the ED. In smaller teams, the HDB focus group then created five individual original HDB frameworks in draft form. ...
Article
Full-text available
Objective: Team-based resuscitation in emergency departments (EDs) is an excellent opportunity for hot debriefs (HDBs). In creating a bespoke HDB model for emergency medicine resuscitations, we sought to optimize learning from clinical experience, identify team strengths, challenges, encourage honest reflection and focus on ways of improving future performance. Methods: Multidisciplinary ED focus groups reviewed existing models, identified benefits/barriers and created new frame works, testing and adapting further using fottage of a simulated complex resuscitation case. The new HDB tool was coined: "STOP5" (STOP for 5 minutes). Cases targeted were prehospital retrievals, major trauma, cardiac arrests, deaths in resuscitation, and staff-triggered. The framework details included a specifically scripted introduction followed by core elements that were S: summarize the case; T: things that went well; O: opportunities to improve; P: points to action and responsibilities. Staffs were surveyed at 1 month prior then 6 and 18 months post-introduction. Data collection forms were used to identify and track hard outcomes/system improvements resulting directly from HDBs. Results: Potential benefits identified by respondents included: improved staff morale; team cohesion; improved care for future patients; promoting a culture for learning, patient safety and quality improvement. Ten process and equipment changes resulted directly from STOP5 over 12 months. Conclusion: We anticipate the STOP5 framework to be globally generalizable and effective for many ED teams.
... 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. ...
Article
Full-text available
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.
... This is often done through group reflection on the shared experience, which is known as debriefing in the clinical context. 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. ...
... 82 Debriefing in healthcare aims to facilitate discussion of actions and thought processes regarding adverse events, encourages reflections on practice, and eventually can lead to implementing new agreed practices and behaviours derived from such reflections. 82 The practice of regular and frequent debriefs after adverse events or medical errors in EDs was identified as key to improving safety culture in their workplace. Debriefing was seen as a strategy that leads to rich learning opportunities, whilst recognising the unique, complex and chaotic environment in which practice occurs. ...
... Although these predetermined compliance levels are below thresholds normally used for high reliability, 22 the study team chose them due to the infrequent levels of debriefing implemented in prior research studies. 19,23,24 ...
Article
Full-text available
Introduction: Pediatric quality improvement (QI) collaboratives are multisite clinical networks that support cooperative learning. Our goal is to identify the contextual facilitators and barriers to implementing QI resuscitation interventions within a multicenter resuscitation collaborative. Methods: A mixed-methods evaluation of the contextual facilitators and barriers to implementation of a resuscitation QI bundle. We administered a quantitative questionnaire, the Model for Understanding Success in Quality (MUSIQ), to the Pediatric Resuscitation Quality (pediRES-Q) Collaborative. Its primary goal is to optimize the care of children who experience in-hospital cardiac arrest through a resuscitation QI bundle. We also conducted semistructured phone interviews with site primary investigators adapted from the Consolidated Framework for Implementation Research qualitative interview guide. Results: All 13 actively participating US sites completed the MUSIQ questionnaire. Total MUSIQ scores ranged from 86.0 to 140.5 (median of 118.7, interquartile range 103.6-124.5). Evaluation of the QI team subsection noted a mean score of 5.5 for low implementers and 6.1 for high implementers (P = 0.02). We conducted 8 interviews with the local QI team leadership. Contextual facilitators included a unified institutional approach to QI, a fail forward climate, leadership support, strong microculture, knowledge of other organizations, and prioritization of goals. Contextual barriers included low team tenure, no specific allocation of resources, lack of formalized QI training, and lack of support and buy-in by leaders and staff. Conclusions: Using mixed methods, we identified an association between the local QI team's strength and the successful implementation of the QI interventions.
... Routine debriefing also facilitates understanding of system resources and constraints [11]. Debriefing methods have been largely adopted and adapted from aviation and psychology and there are many models of both post-simulation and clinical event debriefing [11][12][13][14][15][16][17][18][19]. ...
Article
Full-text available
Safety science in healthcare has historically focused primarily on reducing risk and minimizing harm by learning everything possible from when things go wrong (Safety-I). Safety-II encourages the study of all events, including the routine and mundane, not only bad outcomes. While debriefing and learning from positive events is not uncommon or new to simulation, many common debriefing strategies are more focused on Safety-I. The lack of inclusion of Safety-II misses out on the powerful analysis of everyday work. A debriefing tool highlighting Safety-II concepts was developed through expert consensus and piloting and is offered as a guide to encourage and facilitate inclusion of Safety-II analysis into debriefings. It allows for debriefing expansion from the focus on error analysis and “what went wrong” or “could have gone better” to now also capture valuable discussion of high yield Safety-II concepts such as capacities, adjustments, variation, and adaptation for successful operations in a complex system. Additionally, debriefing inclusive of Safety-II fosters increased debriefing overall by encouraging debriefing when “things go right”, not historically what is most commonly debriefed.
... Sie ermöglichen eine Standardisierung und eine Strukturierung im Sinne eines Leitfadens für den Debriefer. Sie können zugleich zur Dokumentation der Besprechung dienen [14,26]. Diese Aspekte können zu einer Verbesserung der Debriefing-Qualität führen. ...
Article
Full-text available
Communication errors and system problems negatively impact teamwork and shared decision-making and can cause patient harm. However, regular debriefings after critical events positively impact teamwork and patient outcome in pediatric emergency care. Team reflection promotes learning, helps teams to improve and to minimize errors from being repeated in the future. Nevertheless, debriefings in daily practice have not yet become a standard quality marker. Reasons include lack of time, lack of experienced debriefers and lack of support from the key stakeholders. Debriefings can take place at different timepoints with variable duration as needed. Due to the global pandemic, virtual debriefings or hybrid events with a mix of virtual and in-person participation are not only currently relevant but may perhaps also be of future relevance. Debriefings should focus on collaborative learning and future-oriented improvements. Not only life-threatening events but also potentially critical situations such as routine intubations warrant debriefings. Debriefing scripts promote a structured approach and allow even inexperienced moderators to navigate all relevant aspects. In addition to areas of challenge, debriefings should also explore and reinforce positive performance to facilitate learning from success. Debriefers should discuss not only obvious observable accomplishments, but also motivations behind key behaviors. This strategy promotes needs-based learning and focuses on solutions. Helpful strategies include specific questioning techniques, genuine interest and a positive safety culture.
... One contributing factor is the perceived difficulty of facilitating debriefing conversations [22,[25][26][27][28][29]. Although debriefing is best facilitated by trained debriefers, there are literature, courses, and videos freely available on the numerous approaches for how to structure debriefing, create a psychologically safe and engaging setting, use of co-debriefing, and the management of difficult debriefing situations [5,23,[30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45]. Another contributing factor is logistical barriers such as high workload, interprofessional scheduling issues, social distancing, or lack of interest [22,23,46]. ...
Article
Full-text available
Background The goal of this study was to identify taken-for-granted beliefs and assumptions about use, costs, and facilitation of post-event debriefing. These myths prevent the ubiquitous uptake of post-event debriefing in clinical units, and therefore the identification of process, teamwork, and latent safety threats that lead to medical error. By naming these false barriers and assumptions, the authors believe that clinical event debriefing can be implemented more broadly. Methods We interviewed an international sample of 37 clinicians, educators, scholars, researchers, and healthcare administrators from hospitals, universities, and healthcare organizations in Western Europe and the USA, who had a broad range of debriefing experience. We adopted a systemic-constructivist approach that aimed at exploring in-depth assumptions about debriefing beyond obvious constraints such as time and logistics and focused on interpersonal relationships within organizations. Using circular questions, we intended to uncover new and tacit knowledge about barriers and facilitators of regular clinical debriefings. All interviews were transcribed and analyzed following a comprehensive process of inductive open coding. Results In total, 1508.62 min of interviews (25 h, 9 min, and 2 s) were analyzed, and 1591 answers were categorized. Many implicit debriefing theories reflected current scientific evidence, particularly with respect to debriefing value and topics, the complexity and difficulty of facilitation, the importance of structuring the debriefing and engaging in reflective practice to advance debriefing skills. We also identified four debriefing myths which may prevent post-event debriefing from being implemented in clinical units. Conclusion The debriefing myths include (1) debriefing only when disaster strikes, (2) debriefing is a luxury, (3) senior clinicians should determine debriefing content, and (4) debriefers must be neutral and nonjudgmental. These myths offer valuable insights into why current debriefing practices are ad hoc and not embedded into daily unit practices. They may help ignite a renewed momentum into the implementation of post-event debriefing in clinical settings.
... 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. ...
Article
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.
... 35 Versions of PEARLS have been adapted for healthcare debriefing and systems-focused debriefing. 32 36 The Debriefing In-Situ Conversation after Emergent Resuscitation Now tool was developed in the study of resuscitations at a paediatric ED. 37 An adapted version was created during the COVID-19 pandemic for end-of-shift debriefing in EDs (Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End). 38 There is a large body of literature from medical simulation and other disciplines supporting critical event debriefing. ...
... 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]. ...
Article
Full-text available
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.
... Clinical debriefing leads should disseminate the benefits of debriefing for improvement, wellbeing and resilience [4-9, 17, 24] in order to encourage staff to engage with debriefing processes. We suggest that CD sessions are brief and follow a structure familiar to the team such as TALK © [29], DIS-CERN [30], INFO [31], TeamSTEPPS [32] or DISCOVER-PHASE [33]. ...
Article
Full-text available
The COVID-19 pandemic and the subsequent pressures on healthcare staff and resources have exacerbated the need for clinical teams to reflect and learn from workplace experiences. Surges in critically ill patients, the impact of the disease on the workforce and long term adjustments in work and life have upturned our normality. Whilst this situation has generated a new ‘connectedness’ within healthcare workers, it also continues to test our resilience. An international multi-professional collaboration has guided the identification of ongoing difficulties to effective communication and debriefing, as well as emerging opportunities to promote a culture of dialogue. This article outlines pandemic related barriers and new possibilities categorising them according to task management, teamwork, situational awareness and decision making. It describes their direct and indirect impact on clinical debriefing and signposts towards solutions to overcome challenges and, building on new bridges, advance team conversations that allow us to learn, improve and support each other. This pandemic has brought clinical professionals together; nevertheless, it is essential to invest in further developing and supporting cohesive teams. Debriefing enables healthcare teams and educators to mitigate stress, build resilience and promote a culture of continuous learning and patient care improvement.
... Community healthcare workers believe that critical event debriefing provides an avenue to review medical care, discuss errors, develop guidelines, build team morale, and provide emotional support [17][18][19][20]. In clinical settings where debriefing is carried out effectively, there is evidence that debriefing sessions can be used as an opportunity to foster learning and help healthcare workers reflect on both their personal and professional values and judgment. ...
Article
Introduction Medical error is currently the third major cause of death in the United States after cardiac disease and cancer. A significant number of root cause analyses performed revealed that medical errors are mostly attributed to human errors and communication gaps. Debriefing has been identified as a major tool used in identifying medical errors, improving communication, reviewing team performance, and providing emotional support following a critical event. Despite being aware of the importance of debriefing, most healthcare providers fail to make use of this tool on a regular basis, and very few studies have been conducted in regard to the practice of debriefing. This study ascertains the frequency, current practice, and limitations of debriefing following critical events in a community hospital. Design/Methods This was a cross-sectional observational study conducted among attending physicians, physician assistants, residents, and nurses who work in high acuity areas located in the study location. Data on current debriefing practices were obtained and analyzed using descriptive statistics. Results A total of 130 respondents participated in this study. Following a critical event in their department, 65 (50%) respondents reported little (<25% of the time) or no practice of debriefing and only 20 (15.4%) respondents reported frequent practice (>75% of the time). Debriefing was done more than once a week as reported by 35 (26.9%) of the respondents and was led by attending physicians 77 (59.2%). The debrief session sometimes occurred immediately following a critical event (46.9%). Although 118 (90%) of the respondents feel that there is a need to receive some training on debriefing, only 51 (39%) of the respondents have received some form of formal training on the practice of debriefing. Among the healthcare providers who had some form of debriefing in their practice, the few debrief sessions held were to discuss medical management, identify problems with systems/processes, and provide emotional support. Increased workload was identified by 92 (70.8%) respondents as the major limitations to the practice of debriefing. Most respondents support that debriefing should be done immediately after a critical event such as death of a patient (123 [94.6%]), trauma resuscitation (108 [83.1%]), cardiopulmonary arrest (122 [93.8%]), and multiple casualty/disasters (95 [73.1%]). Conclusions In order to reduce medical errors, hospitals and its management team must create an environment that will encourage all patient care workers to have a debriefing session following every critical event. This can be achieved by organizing formal training, creating a template/format for debriefing, and encouraging all hospital units to make this an integral part of their work process.
Poster
Full-text available
Methods A snap audit was performed in each operating theatre to ascertain if a pregnancy test had been performed for female patients aged 12–59 years. If no test was performed, the reason documented was recorded if available. An electronic staff survey was distributed amongst nurses, healthcare support workers, anaesthetists, surgeons and theatre staff to assess levels of knowledge surrounding pregnancy testing. Focus groups on each of the admitting wards also allowed us to address potential barriers. Results Only 28.5% of women aged 12–59 years had a pregnancy test before arrival in theatre. This increased to 64% of women aged 12–50 years. Menopause was the commonest reason given for not testing, although 19% had no documented reason. The electronic survey received 133 responses, with disparate results. Up to 25% of staff indicated that they would only perform a pregnancy test if there was doubt about the date of the last menstrual period. In relation to contraception, 13% would not perform a test on women taking the oral contraceptive pill, 20% if they had an intrauterine device, and 19% stating that they would offer the test regardless of contraception use. Ninety‐six per cent were aware of the risk of miscarriage, and 73% of the risk of congenital abnormalities. Discussion The results of the snap audit showed that not all women were being appropriately offered a pregnancy test. There were a number of possible reasons identified by the electronic survey and focus groups including a misunderstanding of the effectiveness of different forms of contraception and the risks of anaesthesia and surgery to an early pregnancy. After compiling our results, we will deliver an education programme to ward staff and work with a multidisciplinary team to compose a guideline for pregnancy testing before theatre. A monthly re‐audit will allow us to assess the effectiveness of our intervention.
Chapter
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.
Article
Background: Debriefing clinical events in the emergency department (ED) can enhance team performance and provide mutual support. However, ED debriefing remains infrequent and nonstandardized. A clinical tool (DISCERN-Debriefing In Situ Conversation after Emergent Resuscitation Now) was developed to facilitate ED debriefing. To date, there are no studies providing qualitative analysis of clinical event debriefs done using such a tool. Our goal was to explore common themes elicited by debriefing following implementation of DISCERN. Methods: This was a retrospective mixed-methods study analyzing DISCERN data from 2012 through 2017 in a pediatric ED. Quantitative data were analyzed using descriptive statistics. With constant comparison analysis, themes were categorized when applicable within the context of crisis resource management (CRM) principles, previously used as a framework for description of nontechnical skills. Member checking was performed to ensure trustworthiness. Results: We reviewed 400 DISCERN forms. Overall, 170 (41.6%) of target clinical events were debriefed during the study period. The number of clinical events debriefed per year decreased significantly over the study period, from 118 debriefed events in 2013 to 20 debriefed events in 2017 (p < 0.001). Events were more likely to be debriefed if cardiopulmonary resuscitation was needed (odds ratio [OR] = 11.8, 95% confidence interval [CI] = 4.1-33.8]) or if the patient expired (OR = 8.9, 95% CI = 2.7-29.1]). CRM principles accounted for 81% of debriefing statements, focusing on teamwork, communication, and preparation, and these themes remained consistent throughout the study period. Conclusions: Use of the DISCERN tool declined over the study period. The DISCERN tool was utilized more commonly after the highest-acuity events. Clinical event debriefs aligned with CRM principles, with medical knowledge discussed less frequently, and the content of debriefs remained stable over time.
Article
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.
Article
Background Clinicians working in the ED setting are exposed to traumatic and stress-inducing incidents, which may increase the incidence of psychological sequelae, including burnout and acute stress disorders. The purpose of this project was to develop and implement a novel debriefing program as an early intervention for acutely stress-inducing events in the emergency department. Methods The 2-stage Acute Incident Response program was developed and implemented in the emergency department of the John Hunter Hospital to guide an interprofessional response to acutely stress-inducing incidents. This psychological support framework draws on existing concepts of critical incident stress management along with elements of contemporary “hot debriefing” models to create a concise, clinician-led response program incorporating elements of both work group peer support and clinical team performance improvement. The Acute Incident Response program is novel in its concurrent focus on both salient clinical factors and emotional responses of affected clinicians. Results The developed Acute Incident Response program framework predominantly focuses on the wide dissemination of a peer-driven debriefing model. When additional support is deemed necessary by trained clinical champions after the Hot Acute Incident Response process, escalation to a central response coordinator ensures targeted secondary support follow-up for all affected team members. This program has been introduced at 1 site and warrants further targeted investigation to determine its efficacy and utility in a broad range of clinical contexts. Conclusion The Acute Incident Response program is an accessible and meaningful model to guide a functional, clinician-led response to acute incidents in the ED setting. The model could feasibly be applied in a wide variety of clinical contexts.
Article
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.
Conference Paper
Full-text available
Anaesthesia is the largest hospital-based specialty in the UK and is an appealing career to many junior doctors; however, exposure to anaesthetics for Foundation doctors remains limited with only 6.1% of Foundation programmes including anaesthetics [1], leaving many uncertain as to its suitability as a career. We designed a quality-improvement project aiming to bridge this gap between Foundation year doctors and our specialty. Methods We organised and delivered an anaesthetic career workshop for Foundation doctors in the west of Scotland. This consisted of four presentations ranging from application and interviews to life as an anaesthetic trainee and consultant. Feedback demonstrated that we were catering for two audiences, with one group exploring career options and another with firm intentions to apply to anaesthetic training. Subsequently, we modified our approach by holding two separate events: a career workshop and a mock interview course. We provided tailored information about the application, the interview and advice regarding delegates’ portfolios. We also prepared mock interviews for each attendee that reflected the core anaesthetic interview process. Delegates were surveyed to assess whether their expectations had been met. Results Twenty-three delegates attended the initial workshop in June 2019. Domains including expectations, relevance and understanding of anaesthetic careers were assessed using a five-point Likert scale with a mean score of 4.57. Forty-four del- egates attended the second iteration of the workshop in November 2019, scor- ing a mean of 4.60 across the same domains. The outcomes for the mock interview course was a mean score of 4.76, with all eight attendees scoring 5 for feedback obtained, having a better understanding of the interview process and recommending the course to colleagues. Discussion With this ongoing quality-improvement project, we have demonstrated there is a regional need to inform Foundation doctors about a career in anaesthesia. As trainee anaesthetists, we can offer support and guidance to junior colleagues as they navigate these difficult career-defining decisions. By delivering a relevant, practical and educational series of events in our region, we can bridge the gap between Foundation doctors and our specialty and also support those about to embark on the application process. Through this project, we may improve recruitment and retention in anaesthesia and address ongoing challenges in workforce planning [2]
Article
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.
Chapter
Debriefing framework and approach inform a number of factors, including participant group and learning needs, type of predetermined learning objectives, and those debriefing points that emerge from the discussion. Although general principles for healthcare debriefing exist, special considerations apply for emergency care settings. In emergency medicine, debriefings should highlight the unique logistic and cognitive demands on individuals as well as interprofessional, multi-disciplinary teams. One size does not fit all, and debriefing approach for various components of any one simulation scenario are not mutually exclusive. For emergency settings, aspects about individual thought processes, teamwork, and systems issues may be relevant for a single debriefing session. Debriefing is an essential element of healthcare simulation and the information summarized here helps educators develop and implement an informed strategy.
Article
Purpose of review: Although patient safety is a core component of education in anesthesiology, approaches to implementation of education programs are less well defined. The goal of this review is to describe the current state of education in anesthesia patient safety and the ideal patient safety curriculum. Recent findings: Anesthesiology has been a pioneer in patient safety for decades, with efforts amongst national organizations, such as the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation to disseminate key standards and guidelines in patient safety. However, few, if any strategies for implementation of a patient safety curriculum in anesthesiology exist. Summary: Patient safety education is crucial to the field of anesthesiology, particularly with the advancement of surgical and anesthesia technologies and increasing complexity of patients and procedures. The ideal patient safety curriculum in anesthesiology consists of simulation, adverse event investigation and analysis, and participation in process improvement. Efforts in education must adapt with changing technology, shifts in the way anesthesia care is delivered, and threats to physician wellness. Future efforts in education should harness emerging platforms, such as social media, podcasts, and wikis.
Article
Hot debriefing (HoD) describes a structured team-based discussion which may be initiated following a significant event. Benefits may include improved teamwork, staff well-being and identification of learning opportunities. Existing literature indicates that while staff value HoD following significant events, it is infrequently undertaken in practice. Internationally, several frameworks for HoD have been developed, although none are widely adopted for use in the ED. A quality improvement project was conducted to introduce HoD into a single UK ED in North West England, between January and March 2019. Following stakeholder consultation, the 9-item ‘TAKE STOCK’ tool was developed. Implementation of the tool increased the number of HoD (0—2.2 HoD episodes/week). Findings from the first plan-do-study-act (PDSA) cycle are presented, which revealed the key strengths and limitations of this model. Staff perceptions of the tool were evaluated using a self-administered short questionnaire designed by the authors. Satisfaction with TAKE STOCK was assessed using 10-point numerical scales. Across respondents (n−15), average satisfaction scores exceeded 9 out of 10 concerning patient care, staff self-care, decision-making, education, teamwork and identification of equipment issues. Implementation of HoD into the ED is feasible and viewed as beneficial by staff. Implementation toolkits for TAKE STOCK have been requested by 42 additional UK hospitals and ambulance trusts, demonstrating significant interest in its use. Research is now required to formally validate HoD frameworks for use in the ED, and assess whether HoD results in sustained improvements to staff and patient outcomes.
Article
Aims and objectives The purpose of this paper is to enhance nursing and collaborative practice by presenting a concept analysis of clinical debriefing and introducing an operational definition. Background Debriefing has taken many forms, using a variety of approaches. Variations and inconsistencies in clinical debriefing, and its related terms, still exist in the clinical setting. Design Concept analysis. Methods Walker and Avant’s eight‐step approach to concept analysis. Results The defining attributes of clinical debriefing identified in this analysis are described as the five E’s: educated/experienced facilitator, environment, education, evaluation, and emotions. Antecedents identified in this analysis include the critical event, the desire or need to review such an event, and the organizational awareness to execute clinical debriefs. The consequences of clinical debriefings are primarily advantageous and positively impact involved nurses, healthcare teams, patients, and organizations. Empirical referents of clinical debriefing are complex and multifactorial. The productivity of a clinical debrief can be enhanced through a series of proposed questions. Together, the defining attributes, antecedents, and consequences shape a proposed operational definition of clinical debriefing. Conclusion Clinical debriefing is a valuable tool within healthcare organizations. Debriefing can be a holistic, interprofessional, collaborative experience when all five defining attributes are present. Further investigation is required to standardize debriefing practices in clinical settings. Relevance to clinical practice A concept analysis on clinical debriefing promotes uniformity of debriefing practices, reflective practice among nurses and healthcare teams, and contributes to nursing science by creating a platform for the development of practice standards, research, and theory development.
Article
Aim For successful simulation‐based learning (SBL), a structured interactive and bidirectional debriefing should be a prerequisite. The purpose of this study is to identify the effects of instructor‐led hot debriefing (debriefing immediately after simulation) and cold debriefing (debriefing occurring after a certain period following simulation) in simulation with case‐based learning (CBL). Method This study used a nonequivalent control group pretest‐posttest design. A sample of 59 fourth‐year nursing students in South Korea were invited and randomly divided into two groups, a post‐simulation hot debriefing (PSHD, male = 4, female = 26), and cold debriefing (PSCD, male = 3, female = 26). We used clinical performance competency, satisfaction with CBL and SBL, and debriefing tools. The study period was from October to December of 2019. We analyzed the data with SPSS 23.0 software, using descriptive statistics and the t test. Results Clinical performance competency means that the scores of both groups were significantly improved in the posttest (PSHD = 33.13 ± 5.11, PSCD = 34.10 ± 4.15) as compared to those in the pretest (t = −7.010, p < .001). The knowledge (t = −12.689, p < .001) and skill (t = −5.338, p = .001) scores of clinical performance competency in the PSCD were higher than those in the PSHD. The mean satisfaction scores of the PSHD group with CBL (4.53 ± 0.60) and debriefing (4.66 ± 0.55) was higher than for those in the PSCD group. Conclusion As a result of this study, PSHD and PSCD led by an instructor improved student clinical performance competency. The PSHD method, in particular, might be a positive influence on learner satisfaction with CBL, SBL, and debriefing.
Article
Background Prior to the study, debriefings post-real-life cardiopulmonary arrest at the associated hospital were conducted only 3% of the time. However, debriefings post-cardiopulmonary arrests are recommended by multiple entities to improve team performance. Methods A course on teamwork, education on a structured method of debriefing, and debriefing practice via simulated role-play were provided to resuscitation team members. A prospective, mixed methods study including team member perceptions of debriefings and the number of debriefings conducted post-cardiopulmonary arrests were measured after the intervention. Results Debriefings increased from 3% to 39%. Debriefings were valued by all team members. Themes generated from team members’ comments included improvement, communication, and team function. Conclusions Debriefings post-real-life cardiopulmonary arrest events are feasible in a hospital setting. Teamwork principles training with simulated role-play of debriefing can impact the process of whether debriefings occur and are highly regarded by multidisciplinary team members.
Article
Objectives: Event debriefing has established benefit, but its adoption is poorly characterized among pediatric ward providers. To improve patient safety, our hospital restructured its debriefing process for ward deterioration events culminating in ICU transfer. The aim of this study was to describe this process' implementation. Methods: In the restructured process, multidisciplinary ward providers are expected to debrief all ICU transfers. We conducted a multimethod analysis using facilitative guides completed by debriefing participants. Monthly debriefing completion served as an adoption metric. Results: Between March 2019 and February 2020, providers across 9 wards performed debriefing for 134 of 312 PICU transfers (43%). Bedside nurses participated most frequently (117 debriefings [87%]). There was no significant difference in debriefing by unit, acuity, season, or nurse staffing. Compared with units fully staffed by rotational frontline clinicians (FLCs; eg, resident physicians), units with dedicated FLCs whose responsibilities are primarily limited to that unit (eg, oncology hospitalists) completed significantly more monthly debriefings (average [SD] 57% [30%] vs 33% [28%] of PICU transfers; P = .004). FLC participation was also higher on these units (50% of debriefings [37%] vs 24% [37%]; P = .014). Through qualitative analysis, we identified distinct debriefing themes, with teaming activities such as communication cited most often. Conclusions: Implementation of a multidisciplinary debriefing process for ward deterioration events culminating in ICU transfer was associated with differential adoption across providers and FLC staffing models but not acuity or nurse staffing. Teaming activities were a debriefing priority. Future study will assess patient safety outcomes.
Article
Purpose of review: Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal critical event debriefing. Recent findings: Evidence-based key processes to consider for proximal critical event debriefing can be summarized by the WATER mnemonic: Welfare check (assessing team members' emotional and physical wellbeing to continue providing care); Acute/short-term corrections (matters to be addressed before the next case); Team reactions and reflections (summarizing case; listening to team member reactions; plus/delta conversation); Education (lessons learned from the event and debriefing); Resource awareness and longer term needs [follow-up (e.g. safety/quality improvement report), local peer-support and employee assistance resources]. A cognitive aid to accompany this mnemonic is provided with the publication. Summary: There is growing literature on how to conduct proximal perioperative critical event debriefing. Evidence-based best practices, as well as a cognitive aid to apply them, may help bridge the gap between theory and clinical practice. In this era of increased attention to burnout and wellness, the consideration of interventions to improve the quality and frequency of critical event debriefing is paramount.
Article
Background Emergency department nurses are faced with traumatic patient events while functioning as members of multidisciplinary teams. Postresuscitation debriefings have been shown to benefit health care professionals and patient clinical outcomes. The purpose of this study was to examine the relationship between the use of post resuscitation debriefings and perceptions of teamwork in emergency department nurses. The study also addressed the type and timing of debriefing to determine whether these factors are associated with perceptions of teamwork. Methods A nationwide survey was disseminated to emergency department nurses throughout the United States. The design aimed to compare the results from the Nursing Teamwork Survey with the data regarding frequency, type, and timing of debriefings. An ANOVA and Scheffe post hoc was done as well. Results The 68 responses which were included in the data were from 27 different states. Results showed that when debriefings were done more frequently (η = .41, p = .02), were conducted using a formal debriefing method (η = .36, p = .01), and were held immediately after a situation (η = .36, p = .03), there was a significant positive relationship (eta coefficient) with higher levels of trust, team orientation, backup, shared mental model, and leadership. Conclusion Findings may be used to increase utilization of debriefings and improve perceptions of teamwork among emergency department nurses.
Article
Objective In 2013, our intubations highlighted a safety gap – only 49% achieved first-pass success without hypoxia or hypotension. NAP4 recommended debriefing after intubation, but limited published methods existed. Primary aim is to implement a feasible process for immediate debriefing and feedback for emergency airway management. Secondary aims are to contribute to reduced frequency of adverse intubation-related events and implement qualitative improvements in patient safety through team reflection and feedback. Methods A component of a prospective quality improvement (QI) study over 4 years in the ED of the Royal Children's Hospital, Melbourne, Australia. Debrief and feedback after intubation was one of seven study interventions. Targeted staff training and involvement of departmental leaders occurred. A post-intervention cohort was audited in 2016. Analysis included the Team Emergency Assessment Measure. Results Immediate post-event debriefing occurred in 39 (85%) of 46 intubations. Debriefing was short (median duration 5 min, interquartile range [IQR] 5–10) and soon after (median time 20 min, IQR 5–60). Commonest location was the resuscitation room (92%), led by the team leader (97%). Commonest barrier preventing immediate debriefing was excessive workload. Two QI process measures were assessed during debriefing (adequate resuscitation, airway plan) and case summaries distributed for 100% of intubations. Performance outcomes included contribution to 78% first-pass success without hypoxia or hypotension. Team reflection prompted changes to environment (signage, stickers), training (skill drills), teamwork and process (communication, clinical event debriefing). Conclusion Structured and targeted debriefing after intubating children in the ED is feasible and contributes to measurable and qualitative improvements in patient safety.
Chapter
Debriefing skills honed in simulation can be translated to the bedside with the goals to improve patient care and learn from real life clinical scenarios. Pediatric in-hospital cardiac arrest is associated with significant morbidity and mortality; debriefing afterwards has been demonstrated to improve patient outcomes. This chapter discusses the structures and processes of both “hot” and “cold” debriefing after clinical events, and describes how to optimize facilitators, address barriers, and manage difficult situations. Integration of debriefing into comprehensive resuscitation programs can improve resuscitation performance and patient outcomes.
Article
Objective: To describe the use of a postarrest debriefing tool (DBT) within a university teaching hospital and to evaluate user perceptions of the tool. Design: Observational study over a 1-year period and associated hospital clinical personnel survey. Setting: University teaching hospital. Interventions: Qualitative data surrounding the use and utility of the DBT were analyzed, as well as survey results. Measurements and main results: Forty-four arrests occurred during the study period. Debriefing was performed after 26 of 44 (59%) cardiopulmonary resuscitation (CPR) events, of which 22 of 26 (85%) were recorded using the DBT and four without the DBT. Return of spontaneous circulation did not significantly affect the use of the DBT (p = 0.753). Most events in which debriefing was not performed occurred outside of business hours (13/18; 72%). The most frequent positive debriefing comments related to cooperation/coordination within the team (22/167; 13%). The most frequent negative debriefing comments concerned equipment issues (36/167; 22%). Of the action points generated, 57% (34/60) were directed at equipment use/availability. Teams reported that emergency drugs were appropriately administered in 21 of 22 (95%) cases. In contrast, closed loop communication was reportedly only used during 6 of 22 (27%) events. The hospital survey response rate was 56 of 338 (17%) clinical staff, of whom 37 of 56 (66%) agreed or strongly agreed that debriefing had improved team performance during CPR. Overall, 33 of 56 (60%) staff felt that the DBT had improved the debriefing process at the hospital. However, 3 of 56 (5%) staff members felt that they were unable to state their opinions in a blame-free environment during debriefing. Conclusions: Implementation of a DBT enabled formal identification of strengths and training needs of resuscitation teams, and its implementation was viewed positively by the majority of hospital staff. However, further refinement of the tool and prospective studies evaluating its efficacy in improving outcome are warranted.
Thesis
Full-text available
La simulation est devenue un outil pédagogique incontournable dans la formation et le développement des professionnels de santé tant sur un plan individuel que sur le plan du travail en équipe. Cependant, face à l’utilisation croissante de la simulation pour les formations en santé, nombre de questions persistent quant aux mécanismes en jeu dans l’apprentissage par simulation ainsi qu’aux modalités pédagogiques à mettre en œuvre pour optimiser l’efficacité de ces formations. L’objectif de ce travail de thèse vise d’abord une meilleure compréhension du processus d’apprentissage expérientiel à l’œuvre lors d’une session d’apprentissage par simulation pour ensuite proposer une structuration des phases du débriefing susceptibles de favoriser l’acquisition de nouvelles connaissances déclaratives et procédurales. Une première étude a permis de montrer l’efficacité de la mise en place de situations simulées lors des formations aux gestes et soins d’urgence. Une deuxième étude a confirmé l’intérêt d’un programme de simulation construit selon les principes d’apprentissage expérientiel de Kolb (1984) sur les réactions, apprentissages et comportements de soignants expérimentés travaillant en équipes pluri-professionnelles de structure mobile d’urgence et de réanimation (SMUR). Ce travail s’est ensuite centré sur la place accordée au débriefing dans l’apprentissage par simulation. Une troisième étude a précisé la place du débriefing dans l’évolution du sentiment d’efficacité personnelle des apprenants et, dans la lignée des travaux sur l’enseignement explicite, a montré la supériorité des approches structurées et explicites du débriefing par rapport aux approches implicites et réflexives pour l’apprentissage de connaissances déclaratives chez les apprenants novices (étudiants infirmiers). Une quatrième étude a ensuite montré que, pour des apprenants expérimentés en équipes pluri-professionnelles de service d’urgence, le débriefing explicite s’avérait aussi efficace qu’un débriefing réflexif sur l’évolution des connaissances déclaratives, du sentiment d’efficacité personnelle ainsi que sur les modifications comportementales. Sur un plan pragmatique, les résultats de ce travail apportent des éléments pour la mise en œuvre d’une session d’apprentissage par simulation en santé et notamment sur la manière de structurer les différentes séquences de débriefing selon le public considéré.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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].