>Operator:
On behalf of the American Heart Association, hello and welcome to today's webcast, “Best Practices for In hospital Post Resuscitation Debriefing”. My name is Jamieson, I will be your Web Event Specialist today. All lines have been placed on mute to prevent any background noise. Please note that today's webcast is being recorded.
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It is now my pleasure to turn today's program over to Liz Olson with the American Heart Association. Liz, the floor is yours.
>Liz Olson:
Thank you so much. On behalf of the American Heart Association and Get With the Guidelines – Resuscitation, I would like to welcome everyone to today's webinar, “Best Practices for In hospital Post Resuscitation Debriefing.” My name again is Liz Olson and I’m the National Program Manager for the Get With The Guidelines - Resuscitation program.
On today’s webinar, we will have the opportunity today to hear from our presenter, Dr. Taylor Sawyer, who will walk us through some best practices for in-hospital post-resuscitation hold and cold debriefing across all patient populations including resources for use in your hospital.
We invite you to submit questions throughout today's presentation by using the “Q&A” button in the lower corner of your screen. At the end of today’s presentation we allow time for questions and a recording of today's webinar will be available on the American Heart Association website, heart.org/quality.
It's now my pleasure to introduce our speaker for today. Dr. Taylor Sawyer is a neonatologist and an Assistant Professor of Pediatrics at the University of Washington School of Medicine and Seattle Children's Hospital. He is the Director of the Neonatal-Perinatal Medicine Fellowship at UW and also the Director of the Neonatal Education and Simulation-based Training Program. His research interests include the use of simulation for neonatal resuscitation and procedural skills training and investigating debriefing methods used in simulation training and clinical care. He’s a member of the American Heart Association Get With The Guidelines Resuscitation Pediatric Research Task Force and a provisional member of the International Liaison Committee on Resuscitation (ILCOR), Neonatal Life Support Task Force.
It's now my pleasure to turn our presentation over to Dr. Taylor Sawyer. The floor is yours.
>Taylor Sawyer:
Thank you, Liz. I definitely appreciate the invitation to talk today on a topic that I've been very interested in for the past several years and today we are going to talk about “Best Practices in In Hospital Post Resuscitation Debriefing.”
I have no significant disclosures in regards to this talk. And the learning objectives today are to review the methods for post event debriefing, to explain the benefits of post event debriefing and then to identify some potential barriers that people experience in conducting debriefings and some strategies to overcome those barriers.
My outline is to look at briefly the history of post event debriefing, examine some best practices for in hospital post resuscitation debriefing and we’ll look at the what, why, when, where, who, and how and then potential barriers will be explored.
Before I start, I just want to begin with a clinical case. This is a fictional case of a 64 year old man visiting a Children's Hospital who drops to the floor with sudden onset chest pain. You can see from the picture there you might recognize the film star in this photo but just for the sake of our conversation, let's say that he was visiting the hospital, dropped to the floor with sudden chest pain and the Code Blue team was activated. In response to this, the pediatric Code Team arrived to the scene and found our victim not breathing and pulseless. The team initiated cardio-pulmonary resuscitation and identified a shockable rhythm however there was a brief discussion and a bit of confusion on the appropriate dose because the pediatric team was used to the dealing with joules per kilo. Some other minor team performance issues were identified due to the infrequency of adult codes in this Children's Hospital. And there were some specific questions on the ACLS algorithm.
So the first question, and you can do this as a poll, is what should the team do after this man is stabilized and transported to the adult hospital? And I will put up some potentials and then we will do a quick poll to see what the group thinks. The first thing the team could do is continue on with their day because it's really busy. It's always obviously very busy in the hospital so sometimes that is the default method is to continue on with the day. The other option is to talk and gossip about the events for the next few weeks. Or the third is to conduct a post event debriefing focusing on teamwork and process improvement. So let me open the poll now. And you are able to click your answer.
I see the numbers rolling in here. I will give you five more seconds to answer. Okay. So we will stop the poll and then I'm going to put the results here. And hopefully you can see those. A little bit of foreshadowing based on the name of the topic here, but 99 percent voted for conduct a post event debriefing focusing on teamwork and process improvement. I would agree with that as well that, that is the best way to do that and we will come back to this clinical case at the end.
So just before we get into the topic of how to do debriefings, let's talk briefly about the history of post event debriefings. This is sort of a general conversation but definitely related to resuscitation debriefings. So if you look at the history of debriefing, probably the earliest reports of it were in the military and this is a guide to what the military refers to after action reviews, which is the Army’s form of debriefing. And in the history of debriefing really the major work in this area was performed at the National Training Center in Fort Irwin and a lot of research has gone into the methods that the military uses to conduct debriefings.
A little personal story from myself is prior to coming to the University of Washington Seattle Children’s, I was an Army, active duty Army Neonatologist for 11 years and as part of that role I was deployed to Iraq in 2008 2009. Prior to that deployment, I did participate in a training exercise at the National Training Center as a military provider conducting Army simulations of combat casualty care.
This is a picture of a sort of a training exercise. Here you see that in the National Training Center they have a large simulated Iraqi village and the Army personnel are conducting a casualty evacuation drill here and they are bringing those casualties back to the Battalion Aid Station.
These are just some pictures of myself. These are simulated trauma casualties and you can see they are realistic simulations. These are actually amputees who are volunteers to be standardized patients for the military personnel to train with. However, myself, as an Army Neonatologist, after – this is shortly after I completed my Fellowship, so that’s three years of Neonatal Fellowship, one year as a General Pediatrician and three years as a Pediatric Resident, I had been seven years out from really caring for an adult, but now I was expected to care for trauma patients in a combat environment.
After each one of these training exercises we had a very well done and facilitated post event debriefing in which case and where the facilitators discussed our performance, deviations, what went well, what could be improved. This is a huge learning opportunity for myself to really not only learn the intricacy of combat casualty care, but also to experience what it was like to go through well designed and research based debriefings.
One thing that continued to go through my mind as a Neonatologist caring for these adults is, where are the babies.
In addition to the Army, the Air Force and NASA has also done significant work on debriefing methods and if you look at a lot of the research and publications around debriefing, in the literature, a lot of it focuses around aviation and the methods that have been utilized to conduct debriefings in that arena.
Debriefing in healthcare has been a relatively recent event specifically an increased focus on the use of debriefings to improve patient care. The TeamSTEPPS curriculum was one of the earliest to focus on the benefits of debriefing and the TeamSTEPPS curriculum includes both briefs, huddles, and debriefs and really focuses on the ways you can conduct an effective debriefing.
So now let's get into some intricacies of how to conduct a post event debriefing. The first question is what is a post event debriefing. There are lots of different definitions of this in the literature but I’d just like to focus on a few. And the first one is by Mullan from JAMA, 2014 where they talk about it as “a discussion of actions and thought processes after an event to promote reflective learning and improve clinical performance”. And then another is from the simulation literature by Fanning and Gaba that discussed debriefing as a “facilitated or guided reflection in the cycle of experiential learning”. I think these two sum it up well in that debriefing should be a facilitated discussion, focused on performance improvement.
There is a difference between debriefing and other forms of – other conversations that can be had after resuscitation or clinical event. Those other events could be defined as defusing or counseling. Defusing is more has been described more as like a venting of emotions or to reduce tensions and then counseling is a specific event focused on aiding employees from being a second victim and typically conducted by mental health experts.
For the purposes of this conference, we really need to differentiate those two. Obviously after any resuscitation there could be the need for further on counseling, but the conversation today will focus specifically on the debriefing which typically does not deal with the emotional content of the events that happened however that might be something that is required to follow up after the clinical debriefing if a significant trauma has been experienced by the participants.
So what events should be debriefed? The webinar today focuses on resuscitations however debriefings don't necessarily need to only focus on resuscitations. Debriefings could be conducted after procedures, after any near misses or medication errors, emergent transfers or any really challenging patient or even the parent interaction in the field of pediatrics. Any of these are rife with areas for process improvements and are great places to utilize debriefing to improve the care that we provide.
And it should not be limited to events with poor outcomes. It's nice to focus on those things that have done well as well. So the performance pieces that led to that exemplary performance can be highlighted and sustained.
So why should we conduct post event debriefings? The Agency for Healthcare Research and Quality who are the creators of the TeamSTEPPS curriculum have done an investigation and identified three primary areas where debriefing is found to be beneficial. The first one is it improves overall performance. Second, it reduces the frequency of equipment related issues. So you can imagine that if you identify a broken piece of equipment and that's discussed in the debriefing, you can rapidly repair that and fix that for the next patient care interaction that goes on in that space. And it also enhances communication and teamwork.
There's quite a bit of literature on the benefits of debriefing. And these are just a few over the past several years. A publication by Edelson where they talk about debriefing using CPR quality data to improve rates of return of spontaneous circulation. Another report by Jiang where they used regular feedback and video recordings to improve the quality of CPR. And then a more recent publication by Wolfe where they looked at interdisciplinary post event debriefings and then association with those and improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcomes. As many of you know, post resuscitation debriefing is endorsed by the American Heart Association.
So a bit more evidence, there was a recent meta analysis of an individual and team debriefs conducted by Tannenbaum in 2013 and they noted in a meta analysis of 46 studies that debriefings were associated with an average a 20 25 percent improvement in performance.
And it actually worked equally well with teams and individuals. But debriefings work best when they were aligned so basically if it would be -- the goal was to improve team performance, then the debriefing should focus on team and what makes teams perform well rather than the individuals within teams and vice versa. So if it was interested in individual performance, that debriefing should focus on individual performance. They also noted that debriefings are performed most effectively when they are structured and facilitated. We will discuss some ways that that can be done.
So when should the debriefing occur? So there are lots of different options here and we will open this one up to a brief poll as well. So the first option would be as soon as possible after the event, so within minutes to hours. The next would be maybe within a few days delaying it a bit. Alternatively, it could be after a few days to let sort of people calm down and have an ability to sort of capture their thoughts and come back together at a later period of time. And then the last one would be weeks to months after the event. So let's open that up to a poll. And I'll give everyone a few seconds here to answer. Alright, I see the answers rolling in. We will give it maybe five more seconds here to cast your vote. Alright, we will stop it now. And we will see the results here. Alright, so we had almost 90 percent that felt as soon as possible within minutes to hours. 8 percent within a few days. And then just a couple percent after a few days and just one person, weeks to months later. So we will talk about the benefits to the different time periods here in a bit.
And the real difference here is what people commonly define as hot versus cold debriefing. So hot debriefing would be a debriefing performed shortly after the event, within minutes to hours. And a cold debriefing would be one that is conducted later on.
So the benefits of a hot debriefing are that the entire team is present. You can get ideally the entire interprofessional group. The recall bias is minimized so people should be able to immediately remember the event they just participated in. And then any urgent issues can be immediately addressed and we talked briefly before about broken equipment issues and systems problems. So if those are identified within the clinical space, ideally those could be quickly repaired in advance of the next patient interaction.
The benefits of a cold debriefing would be that it provides a period for folks to cool off and have them reflect on their own performance and it potentially allows a longer time to discuss issues because moving it away from that immediate clinical environment, the team would not be actively engaged in patient management. Many of you have experienced after the resuscitation, there's a lot of follow on care that needs to be conducted, so it's difficult for people to break away from their clinical duties to participate in the debriefing. And then also you can involve leadership if you schedule it at a certain time away from the acute event then you can get potentially get leadership to come to the actual debriefing to hear firsthand from the participants and to ensure that systems issues can be addressed.
Where should the debriefing happen? Now there are multiple locations but they specifically break down into two specific areas, one is the clinical areas such as the patient room or in the hallway outside the patient room. And then the other is nonclinical areas such as conference rooms or break rooms. And I think based on the patient privacy and HIPPA issues, probably the best one, and the one that has the most weight in this argument, is a non-clinical area so probably a conference room, a break room or another private location where the medical team can meet and discuss in a protected area.