GREAT simulation debriefing

Abstract

Context and setting Debriefing is an essential part of simulation used for education and training. We developed a simple checklist to assist debriefing after simulations of medical emergencies and to ensure that best practice is being applied. The debriefing checklist is based on the mnemonic GREAT: G = Guidelines: the facilitator must have the most recent best-evidence guidelines and local policy guidelines for managing the situation being simulated. R = Recommendations: if comprehensive guidelines are not available then recommendations such as those contained in published reviews should be used. E = Events: participants are given time to reflect on the simulation and identify what were the important events (e.g. the patient began fitting). A = Analysis: were signs identified promptly, how did treatments given compare with guidelines and recommendations, were resources used effectively, etc.? T = Transfer of knowledge to clinical practice: what has been learned to improve patient care? Are there any key ‘take-home messages’? Why the idea was necessary Debriefing has not been used widely in medicine and is rarely conducted in a way designed to improve future performance. The use of simulation in medical education is growing rapidly, so a simple guide to focus students on the educational goals of the simulation would be useful to help facilitators new to debriefing a simulation. What was done Aviation debriefing literature was used to identify the generic features of responding to an emergency or crisis. Several debriefing aids were tested in the simulation unit before we adopted GREAT. Evaluation of the results and impact A simulation course for post-anaesthesia care nurses included a scenario that resulted generally in a cardiac arrest. When the video of their performance was viewed during the debriefing, participants were very surprised that treatment deviated from the International Liaison Committee on Resuscitation (ILCOR) guidelines as much as it did. All had current resuscitation certification and realised that during a stressful event it can be difficult to recall important information accurately. Items identified for ‘transfer’ to the workplace included having a copy of the ILCOR algorithm attached to every cardiac arrest cart and for the team leader to use it. In another example, rural general practitioners needed to perform emergency endotracheal intubation. This was accomplished with difficulty by participants, but was not identified as an issue during debriefing. However, when the ILCOR guidelines were presented it became apparent that the manner in which intubation was achieved was outside accepted limits. Participants then discussed what other guidelines they might not be following and resolved to review other emergency care guidelines related to their practice. Use of standard operating procedures is important in crisis management. We have identified that individual and local procedures may be at variance with current guidelines, so that debriefing relying only on the memory of them is unhelpful or even dangerous. The GREAT checklist encourages participants to use guidelines published and validated by peak organisations to benchmark their practice and improve patient care. Recent feedback from users indicates that GREAT can also be used to facilitate debriefing after real clinical events.