Postevent Debriefing Research Articles

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

BackgroundExtensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback...

Acute-on-Chronic Lithium Toxicity: A Simulation Case for Emergency Medicine Residents.

Simulation-based education has become standard within emergency medicine training. Toxicological clinical presentations are challenging to identify and treat in the emergency department. Recognizing that active teaching methods are superior to standard lecture for learner retention, we created an experiential simulation case for education on lithium toxicity. The case was written after an extensive literature review followed by consultation with a medical toxicologist and an expert in simulation-based education. Fifty-three residents participated in a simulation scenario involving a lithium-poisoned patient over the course of eight simulation sessions. The scenario ran approximately 10 minutes and was followed by postevent debriefing. Debriefing was facilitated by an emergency medicine attending with specialized training in simulation-based education. Following the completion of the scenario, residents received an anonymous educational quality improvement survey assessing residents' perception of their ability to recognize and manage lithium toxicity as well as their comfort level with the lithium-poisoned patient. After the simulation, residents reported an increased comfort level with managing lithium-poisoned patients. Residents also self-reported an increased ability to recognize the signs and symptoms of lithium toxicity. Additionally, residents cited the case's educational importance and a desire to include this specific scenario in future simulation sessions. Compared to other disease processes, toxicological overdoses are infrequently seen in the emergency department. Health care simulation can effectively portray lithium toxicity for emergency medicine resident education in a safe, controlled environment to increase repetitive practice in caring for this challenging population.

Using an OSCE to Explore the Role of Structured Debriefing and Self-Directed Learning in Simulator-Based Clinical Skill Training in Production Animal Reproductive Medicine.

Self-directed learning is associated with several benefits in simulation-based clinical skill training and can be complemented by feedback in the form of post-event debriefing. In this study, final-year veterinary medicine students (n = 111) were allocated into one of three groups and practiced four clinical skills from the domain of production animal reproductive medicine in a clinical skills laboratory. Group 1 completed an instructor-led practice session (I), group 2 completed a self-directed practice session with post-event debriefing (D), and group 3 completed a self-directed practice session without debriefing (control, C). Each practice session included two clinical skills categorized as being directly patient-related (patient) and two clinical skills involving laboratory diagnostics or assembling equipment (technical). Students evaluated the practice session using Likert-type scales. Two days after practice, 93 students took part in an objective structured clinical examination (OSCE). Student performance was analyzed for each learning station individually. The percentage of students who passed the OSCE did not differ significantly between the three groups at any learning station. While the examiner had an effect on absolute OSCE scores (%) at one learning station, the percentage of students who passed the OSCE did not differ between examiners. Patient learning stations were more popular with students than technical learning stations, and the percentage of students who passed the OSCE was significantly larger among students who enjoyed practicing at the respective station (90.9%) than among those who did not (77.8%).

Cardiac Arrest Quality Improvement: A Single-Center Evaluation of Resuscitations Using Defibrillator, Feedback Device, and Survey Data

BackgroundHigh-quality cardiopulmonary resuscitation is foundational to cardiac arrest care. Visual feedback devices can improve chest compression quality, but are infrequently used. Quality improvement data were examined to determine whether handheld visual feedback and backboard use improved chest compression quality, whether resuscitation team size affected resuscitation indicators, and whether feedback sources are comparable. MethodsFrom August 2019 to December 2020, data from 50 resuscitations were collected using a handheld device (n = 35), defibrillator (n = 23), and surveys (n = 35) and shared with providers. Aggregated and individual case data, along with education and research, were distributed to staff as quality improvement measures. ResultsThe mean duration of resuscitation was 1080 compressions (SD = 858); there were no differences in the durations of resuscitations that did or did not use handheld feedback; 50% of resuscitations used handheld feedback and had more compressions at target rate (74.68% vs 42.18%, t(21) = 2.99, P = .007). Moreover, 25% of resuscitations used backboards; these had more chest compressions at target depth (72.92% vs 48.73%, t(25) = 2.08, P = .048). Team size was not associated with duration of resuscitation or chest compressions quality. There was no improvement in other quality indicators (leadership, family presence, or debriefing) during the data collection period. Feedback sources (defibrillator and feedback device) had good agreement and correlation (r = 0.77, P = .01). ConclusionsIncorporating handheld feedback and backboards improved chest compressions quality. Further work to improve the frequency of device use and to examine their relationship to patient-specific outcomes is needed. Study is needed to find interventions that improve other teamwork metrics, inclusion of family during the resuscitation, referral for tissue donation, and rates of postevent debriefing.

Compassionate extubation protocol to improve team communication and support in the neonatal intensive care unit.

ObjectiveCompassionate extubation (CE) can be stressful for staff and families in the neonatal intensive care unit (NICU). Our quality improvement initiative developed and implemented a novel symptom management and family support checklist and post-debriefing template to improve team communication and staff support.Study designAn interprofessional team performed a needs assessment, determined key drivers and intervention steps, and implemented changes using Plan-Do-Study-Act cycles. Outcomes included nursing perception of good communication with the medical team, nursing assessment of patient comfort after CE, and frequency of post-event debrief. Outcomes were analyzed using time series design with 12 months baseline data and 6 months post-implementation monitoring.ResultEighteen events were studied. Respondents endorsing “good” communication with the medical team increased by 60%, and debrief participation rate improved by 96%.ConclusionImplementation of a CE checklist and post-event debriefing sheet was associated with increased rate of debriefs and improved team communication.

Examining the Role of Structured Debriefing in Simulator-Based Clinical Skills Training for Namibian Veterinary Students: A Pilot Study.

Post-event debriefing has been described as an effective tool in improving learning achievements in simulator-based teaching. This article examines the effect of structured post-event debriefing sessions in simulator-based veterinary clinical skills training. Nineteen Namibian veterinary students took part in instructor-led practice, self-directed practice with structured post-event debriefing and self-directed practice without debriefing (control) at three different learning stations in a veterinary clinical skills laboratory. Students evaluated their practice experience using Likert-type scales, and learning achievements were assessed using an objective structured clinical examination (OSCE). The results show that the choice of practice model had no significant effect on learning achievements overall. However, at individual learning stations, different practice models showed significant differences regarding effect on learning achievements. Students generally preferred practice sessions with some form of instructor involvement but the importance of instructor guidance was rated differently at each individual learning station.

\u201cA debriefer must be neutral\u201d and other debriefing myths: a systemic inquiry-based qualitative study of taken-for-granted beliefs about clinical post-event debriefing

BackgroundThe 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.MethodsWe 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.ResultsIn 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.ConclusionThe 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.

Baseline well-being, perceptions of critical incidents, and openness to debriefing in community hospital emergency department clinical staff before COVID-19, a cross-sectional study

BackgroundEmergency 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.MethodWe 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.ResultsThirty-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.ConclusionsAt 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.

Initiation au débriefing pour les internistes : état des connaissances et mise en pratique pour transformer des situations cliniques réelles ou simulées en moments d'apprentissage

Debriefing is a phase of synthesis and reflection that immediately follows a real-life or simulated situation. It is an essential educational step that forces the learners to reflect upon the thought processes that underlie their actions. Debriefing encourages a personal and collective reflection in order to remodel erroneous mental schemas and rectify actions done in context. Debriefing cannot be improvised; it requires a sound structure and regular practice in order to be truly effective. The debriefer must be considerate, choose appropriate learning objectives and dedicate ample time to the learners. Debriefing is focused on learning acquired in context—in other words, on the actions that were performed within a real-life or simulated clinical practice situation—and immediately follows the situation. After an initial phase of emotional release, the debriefer will help learners analyse their actions to identify their underlying rationale (contextualization), extract the overarching principles related to the lived situation in order to modify the rationale if needed (decontextualization) and assist the transfer of learning to real life (in the case of simulation) and to similar situations (recontextualization). A final summary of learning achieved during the training session concludes the debriefing.Debriefing is useful in any learning situation, including in internal medicine. Even if simulation is still underused in internal medicine, post-event debriefing can be implanted in our clinical services. Indeed, training our students and shaping them into healthcare professionals rest in no small part on hospital rotations where the intern is confronted with real-patient situations that are suitable to learning. Some in-hospital clinical encounters can be actively transformed into learning opportunities thanks to post-event debriefing, but can also passively morph into bad daily practice if no supporting action is implemented. Debriefing can thus provide an opportunity to develop non-technical skills in critical situations, or doctor–patient communication skills, within a team or between colleagues. These competencies are the hallmark of well-trained interns and are indispensable for the proper functioning of a care team. We will not develop the emotional and psychological management of debriefing in this article. We hope we will helpfully introduce as many of our colleagues as possible to the art of debriefing in most circumstances.

'Take 10 to talk about it': Use of a scripted, post-event debriefing tool in a neonatal intensive care unit.

This study assessed the impact of a scripted, post-event debriefing tool in identifying logistical, procedural, personnel and performance obstacles and successes in a clinical setting. It was predicted that the debriefing tool would highlight the importance of routine debriefing following challenging clinical events. The study was conducted in a 22-bed neonatal intensive care unit at a tertiary hospital and involved all staff members in the perinatal service. The debriefing tool, a two-page form providing a structured, scripted approach, was used at the earliest opportunity after acute clinical deteriorations, emergency caesarean sections and any other critical events as decided by the neonatal team. Sessions were facilitated by either a nursing or medical member of the neonatal team. Following a 2-month trial, impact was measured via the comparison of before and after survey questions as well as review of a database of issues raised, subsequent actions and outcomes. Significant, positive changes were observed for survey questions specific to the frequency of debriefing, team communication, provision of learning opportunities and identification of logistical, equipment and procedural issues. In addition, the database highlighted the significant positive impact in day-to-day practice as a result of changes initiated by the debriefing tool. All participants requested the unit to continue using the tool. Scripted, post-event debriefing is achievable and valuable in the clinical setting. It encourages a supportive workplace culture and empowers team members to initiate practical change in their organisations.

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

Postevent debriefing has been associated with improved resuscitation outcomes and is recommended by the American Heart Association and the American Academy of Pediatrics to improve clinical performance. Despite the benefits of postevent debriefing, published debriefing programs have focused on single areas within a hospital. We are unaware of any hospital-wide debriefing programs implemented in a pediatric setting. We established a multidisciplinary, interprofessional debriefing collaborative at the Children's Hospital of Philadelphia to implement postevent debriefings in multiple areas of the hospital. The collaborative created a standardized debriefing form to capture data about the postevent debriefings. From July 23, 2015 to December 31, 2017, the emergency department performed 153 debriefings (18%) for 850 resuscitations. The neonatal intensive care unit conducted 10 debriefings (9%) for 107 resuscitations, and the pediatric intensive care unit performed 5 debriefings (7%) for 73 resuscitations. Several departments at the Children's Hospital of Philadelphia have incorporated hot and cold debriefings into their clinical practice as part of their continuous quality improvement programs. By disseminating the tools and lessons learned from the implementation process, the collaborative hopes that other institutions will benefit from their lessons learned to successfully create their own debriefing programs. Widespread adoption of debriefing programs will enable a more scientific approach to studying the outcomes of debriefing.

A Mixed-methods Comparison of Participant and Observer Learner Roles in Simulation Education.

Traditional simulation-based education prioritizes participation in simulated scenarios. The educational impact of observation in simulation-based education compared with participation remains uncertain. Our objective was to compare the performances of observers and participants in a standardized simulation scenario. We assessed learning differences between simulation-based scenario participation and observation using a convergent, parallel, quasi-experimental, mixed-methods study of 15 participants and 15 observers (N=30). Fifteen first-year residents from six medical specialties were evaluated during a simulated scenario (cardiac arrest due to critical hyperkalemia). Evaluation included predefined critical actions and performance assessments. In the first exposure to the simulation scenario, participants and observers underwent a shared postevent debriefing with predetermined learning objectives. Three months later, a follow-up assessment using the same case scenario evaluated all 30 learners as participants. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare participants and observers at 3-month follow-up. In addition, we used case study methodology to explore the nature of learning for participants and observers. Data were triangulated using direct observations, reflective field notes, and a focus group. Quantitative data analysis comparing the learners' first and second exposure to the investigation scenario demonstrated participants' time to calcium administration as the only statistically significant difference between participant and observer roles (316seconds vs. 200 seconds, p=0.0004). Qualitative analysis revealed that both participation and observation improved learning, debriefing was an important component to learning, and debriefing closed the learning gap between observers and participants. Participants and observers had similar performances in simulation-based learning in an isolated scenario of cardiac arrest due to hyperkalemia. Findings support current limited literature that observation should not be underestimated as an important opportunity to enhance simulation-based education. When paired with postevent debriefing, scenario observers and participants may reap similar educational benefits.

The utilisation of a structured debriefing framework within the pre-hospital environment: a service evaluation.

Background:Debriefing improves care and reduces error. To be effective, debriefs should be facilitated by trained individuals utilising structured and validated tools. Currently, in UK ambulance services there is no published evidence that structured processes utilising validated tools are being consistently delivered by trained facilitators, potentially impacting clinical practice.Methods:A pre-intervention survey related to debriefing was sent to 1000 clinicians within a specific geographical area of the trust via e-mail. In addition, 12 senior or advanced paramedics were recruited from the same area to participate in a training day and 12-week trial, utilising the Debrief Diamond as part of post-event debriefing. Following the trial period, all facilitators and participants of any recorded debriefs were invited to complete a post-intervention survey.Results:A total of 130 staff responded to the pre-intervention survey, with 22% reporting that previous debriefs had not identified areas for learning, and 13% reporting that previous debriefs had not identified good practice, learning opportunities or near misses. Post-intervention, 89% believed the process of debriefing was improved utilising a structured framework, 85% stated trained individuals improved the process, 93% reported the identification of good practice, 70% identified team level learning and 100% of facilitators reported improvements in identifying and supporting learning.Conclusion:Improvements in identifying good practice and learning opportunities were reported by both clinicians and facilitators in this evaluation, reflecting current evidence that structured and facilitated debriefs support safer care through the identification and subsequent reduction of human error. Consequently, the evaluation of appropriate debrief frameworks to provide consistency and validity to clinical debriefs in the pre-hospital environment should be considered to support safer clinical care.

Post-event debriefings during neonatal care: why are we not doing them, and how can we start?

Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren't they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for In-Hospital Cardiac Arrest: The Cardiopulmonary Resuscitation Quality Improvement Initiative: Couper K, Kimani PK, Abella BS, et al. Crit Care Med. 2015;43:11:2321-2331.

The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for In-Hospital Cardiac Arrest: The Cardiopulmonary Resuscitation Quality Improvement Initiative: Couper K, Kimani PK, Abella BS, et al. Crit Care Med. 2015;43:11:2321-2331.

Structuring feedback and debriefing to achieve mastery learning goals.

Mastery learning is a powerful educational strategy in which learners gain knowledge and skills that are rigorously measured against predetermined mastery standards with different learners needing variable time to reach uniform outcomes. Central to mastery learning are repetitive deliberate practice and robust feedback that promote performance improvement. Traditional health care simulation involves a simulation exercise followed by a facilitated postevent debriefing in which learners discuss what went well and what they should do differently next time, usually without additional opportunities to apply the specific new knowledge. Mastery learning approaches enable learners to "try again" until they master the skill in question. Despite the growing body of health care simulation literature documenting the efficacy of mastery learning models, to date insufficient details have been reported on how to design and implement the feedback and debriefing components of deliberate-practice-based educational interventions. Using simulation-based training for adult and pediatric advanced life support as case studies, this article focuses on how to prepare learners for feedback and debriefing by establishing a supportive yet challenging learning environment; how to implement educational interventions that maximize opportunities for deliberate practice with feedback and reflection during debriefing; describing the role of within-event debriefing or "microdebriefing" (i.e., during a pause in the simulation scenario or during ongoing case management without interruption), as a strategy to promote performance improvement; and highlighting directions for future research in feedback and debriefing for mastery learning.

Measuring and improving cardiopulmonary resuscitation quality inside the emergency department

Aim of studyTo evaluate CPR quality during cardiac resuscitation attempts in an urban emergency department (ED) and determine the influence of the combination of scenario-based training, real-time audiovisual feedback (RTAVF), and post-event debriefing on CPR quality. MethodsCPR quality was recorded using an R Series monitor-defibrillator (ZOLL Medical) during the treatment of adult cardiac arrest patients. Phase 1 (P1; 11/01/2010-11/15/2012) was an observation period of CPR quality. Phase 2 (P2; 11/15/2012-11/08/2013) was after a 60-min psychomotor skills CPR training and included RTAVF and post-event debriefing. ResultsA total of 52 cardiac arrest patients were treated in P1 (median age 56yrs, 63.5% male) and 49 in P2 (age 60yrs, 83.7% male). Chest compression (CC) depth increased from 46.7±3.8mm in P1 to 61.6±2.8mm in P2 (p<0.001), with the percentage of CC≥51mm increasing from 30.6% in P1 to 87.4% in P2 (p<0.001). CC release velocity increased from 314±25mm/s in P1 to 442±20mm/s in P2 (p<0.001). No significant differences were identified in CC fraction (84.3% P1 vs. 88.4% P2, p=0.1), CC rate (125±3cpm P1 vs. 125±3cpm P2, p=0.7), or pre-shock pause (9.7s P1 vs. 5.9s P2, p=0.5), though CC fraction and pre-shock pause were within guideline recommendations. ConclusionImplementation of the bundle of scenario-based training, real-time audiovisual CPR feedback, and post-event debriefing was associated with improved CPR quality and compliance with CPR guidelines in this urban teaching emergency department.

Implementing an Obstetric Hemorrhage Initiative in an Obstetrics and Gynecology Residency Program [343

INTRODUCTION: Obstetric hemorrhage is the leading cause of preventable maternal mortality worldwide. Between 1994 and 2004, the United States saw a 27.5% increase in maternal deaths and a 92% increase in maternal blood transfusions resulting from hemorrhage. Early recognition of hemorrhage is vital to reducing maternal morbidity. Reports of formal residency campaigns to reduce hemorrhage and educate residents are sparse. The objective of this project was to implement an obstetric hemorrhage initiative in an obstetrics and gynecology residency program. METHODS: From January 2014 to July 2014, the initiative was introduced in a multidisciplinary, collaborative fashion. Champion leads were identified to form an implementation committee from hospital administration, attending physicians, residents, nursing staff, the quality care department, blood bank, and anesthesia. The following were implemented as part of the initiative: formal hemorrhage data tracking system, obstetric massive transfusion protocol, obstetric hemorrhage cart, hemorrhage risk assessment sticker for all obstetric patients, weight-based blood loss quantification system, postevent debriefing, and active management of the third stage of labor. RESULTS: Over a 7-month period, 16 residents were successfully in-serviced on the key introductory obstetric hemorrhage initiative elements, in conjunction with American College of Obstetricians and Gynecologists district XII and the Florida Perinatal Quality Collaborative. In-service was performed through formal lectures and simulation sessions. Barriers to implementation were few. IMPLICATION: With the initial implementation phase complete, residents and staff report increased awareness of and better confidence to deal with peripartum hemorrhage. Data collection continues, with opportunities to track, quantify, and improve our program's maternal hemorrhage over the coming academic year.

Co-debriefing for simulation-based education: a primer for facilitators.

As part of simulation-based education, postevent debriefing provides an opportunity for learners to critically reflect on the simulated experience, with the goal of identifying areas in need of reinforcement and correcting areas in need of improvement. The art of debriefing is made more challenging when 2 or more educators must facilitate a debriefing together (ie, co-debriefing) in an organized and coordinated fashion that ultimately enhances learning. As the momentum for incorporating simulation-based health care education continues to grow, the need for faculty development in the area of co-debriefing has become essential. In this article, we provide a practical toolbox for co-facilitators by discussing the advantages of co-debriefing, describing some of the challenges associated with co-debriefing, and offering practical approaches and strategies to overcome the most common challenges associated with co-debriefing in the context of simulation-based health care education.

Educational opportunities with postevent debriefing.

Educational opportunities with postevent debriefing.