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Crichlow-clinical debriefing
- 1. Post-Trauma Resuscitation Debriefing Amanda Crichlow MD MSMS FAAEM Assistant Professor, Department of Emergency Medicine Medical Director, Center for Simulation Education and Safety Research (CSESaR)
- 2. Objectives • What it is? • Why do it? • Who does it? • When to do it? • How to do it?
- 3. •What it is? • Why do it? • Who does it? • When to do it? • How to do it?
- 4. Debriefing • Facilitated discussion of actions & thought processes • Encourages reflection on actions to improve future performance • Goal is to identify the underlying rationale behind specific behaviors • Feedback is NOT synonymous with debriefing
- 5. Underlying Rationale = Frame Rudolph JW, Simon R, Rivard P, Dufresne R, Raemer DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology Clin. 2007;25:361-75.
- 6. Frames Actions Results All trauma patients get “pan scanned” Resident requests CT head, c-spine, chest/abd/pelvis Patient receives unnecessary imaging 30 yo M presents after MVC @ 40mph Complaints: Left arm pain
- 7. • What it is? •Why do it? • Who does it? • When to do it? • How to do it?
- 8. Why Do It? • Leads to improved performance • Cardiac arrest – improved CPR outcomes • Recommended in AHA and ERC guidelines • Trauma resuscitation data: • Sparse • Focuses on review of video recorded trauma resuscitations
- 9. • What it is? • Why do it? •Who does it? • When to do it? • How to do it?
- 10. Team Debriefing • Multi-professional team debriefing • Physicians, Nurses, Techs, RT, Pharmacy, Radiology, Clerks, etc • Facilitator • Physician or Nurse • Direct Participant or Observer
- 11. • What it is? • Why do it? • Who does it? •When to do it? • How to do it?
- 12. Timing • Typically immediately after event • Delayed when: • Patient has emergent surgical needs • Video review is being incorporated
- 13. Things To Avoid • Do NOT perform after EVERY trauma alert activation • Frequent enough for workflow integration • Not logistically burdensome • Do NOT just focus on events with poor outcomes • Good performance needs to be reinforced
- 14. • What it is? • Why do it? • Who does it? • When to do it? •How to do it?
- 15. Talking Points • Resuscitation Benchmarks: • All team members wear protective equipment • Obtain vital signs within 2 minutes of arrival • Complete primary survey within 10 minutes of arrival • Establish IV access within 5 minutes of arrival
- 16. Talking Points • Communication Benchmarks: • Roles assigned to team members • Closed loop communication used • Additional personnel recruited • Roles adjusted to address new circumstances
- 17. Plus-Delta-Discuss (PDD) Method • Plus: What went well • IV access was obtained within 5 minutes • Delta: What to change for the future • Physical exam findings not clearly communicated • Discuss: Keys to success / barriers • What led to the patient being transported to CT in < 10 minutes? • What were the barriers to performing the FAST expeditiously?
- 18. Pearls To Remember • Focused and succinct • Should not exceed 5-10 minutes • If facilitator is doing all the talking, it’s not a debriefing! • Delivery is as important as content • Tone and body language matter!
- 20. References • Bhanji F, Mancini ME, Sinz E, Rodgers DL, McNeil MA, Hoadley TA, et al. American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care service. Part 16: Education, implementation, and teams. Circulation. 2010;2010:S920-33. • Cheng A, Grant VJ, Sandhu NK. Constructive debriefing for trauma team education. In: Gillman L., Widder S., Blaivas MD M., Karakitsos D. (eds) Trauma Team Dynamics. Springer, Cham. 2016:285-290. • Hoyt DB, Shackford SR, Fridland PH, Mackersie RC, Hansbrough JF, Wachtel TL, et al. Video recording trauma resuscitations: an effective teaching technique. J Trauma Acute Care Surg. 1988;28(4):435–40. • Kessler DO, Cheng A, Mullan PC. Debriefing in the emergency department after clinical events: a practical guide. Ann Emerg Med. 2015; 65(6):690-8. • Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-4. • Rudolph JW, Simon R, Rivard P, Dufresne R, Raemer DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology Clin. 2007;25:361-75. • Soar JK, Monsieurs KG, Ballance JH, Barelli A, Biarent D, Greif R, et al. European resuscitation council guidelines for resuscitation 2010 section 9. Principles of education in resuscitation. Resuscitation. 2010;81:1434-44. • Santora TA, Trooskin SZ, Blank CA, Clarke JR, Schinco MA. Video assessment of trauma response: adherence to ATLS protocols. Am J Emerg Med. 1996;14(6):564–9. • Townsend RN, Clark R, Ramenofsky ML, Diamond DL. ATLS based videotape trauma resuscitation review: education and outcome. J Trauma Acute Care Surg. 1993;34(1):133–8.
Editor's Notes
- I have 5 simple objectives to discuss on post-trauma resuscitation debriefing – what it is? Why do it? Who does it? When to do it? And how to do it? By the completion of this talk the goal is for you all in the spirit of valentine’s day to be in love with debriefing and to have goosebumps at the thought of it
- First let’s discuss what it is?
- A debriefing is a facilitated discussion of a learner’s actions and thought processes. It encourages reflection on actions to improve future performance Our goal when conducting a debriefing is to identify the underlying rationale behind why your learners did what they did Debriefing is not feedback. Feedback is unidirectional approach to addressing specific gaps in individual performance. You can incorporate feedback into a debriefing
- By conducting a brief post-event debriefing you can identify that the resident thinks that all patients with chest pain get MONA. And they develop a new frame with which patient population should receive that intervention instead of indiscriminate CP patients. So when they see the next patient they can then apply the new frame which would modify their actions and yield different results
- To better explain this concept we will use this extreme clinical example: What we see are the actions and the results, what we want to know is why and the why? Is the frame of the practitioner Our goal in post event debriefing is to identify these frames and modify them to improve future performance
- But Why do it?
- Post-event debriefing has been shown to improve outcomes in several areas. Focusing just on cardiac arrest outcomes, post-resuscitation debriefing has been shown to improve CPR outcomes. These outcomes have been so impactful that both the European resuscitation council and the American Heart Association to recommend post-resuscitation debriefing (“Debriefing appears to be an effective method for improving resuscitation performance and, potentially, patient outcomes as long as objective data forms the basis for the discussion”) (“Debriefing of cardiac arrest events, either in isolation or as part of an organized response system, improves subsequent CPR performance in-hospital and results in higher rate of return of spontaneous circulation (ROSC). Debriefing of actual resuscitation events can be a useful strategy to improve future performance”) The trauma resuscitation post-event debriefing data has been primarily focused on the impact of video recording trauma resuscitations in improving performance. (literature!!!) he challenge faced in assessing complex clinical team activities such as trauma resuscitation is developing validated metrics to assess competency. In terms of specific trauma team training tools, there is growing experience since the 1980s in performance review using videotapes as a technique to achieve behavioral changes and algorithm compliance, which has revealed some positive results. Video recording trauma resuscitations and regular review has shown to improve trauma team leadership and the performance of residents in subsequent real-life resuscitations; overall, this method of debriefing seems to lead to reduced time in the emergency department prior to definitive care and improved delivery of key trauma resuscitation interventions.
- Post clinical event debriefing –a multi-professional team debriefing with all the members of your clinical team Depending on the resuscitation – it may be necessary for our clerks and registration to be involved in the debriefing In other formal post-event debriefing programs they are either physician or nursing facilitated, and it can be facilitated by either a direct participant or an observer. There are advantages and disadvantages of either method
- Typically and ideally the debriefing occurs immediately after the event. However they are times when the debriefing will have to be delayed such as when the patient has emergent surgical needs (laparotomy) or when video review is being incorporated
- It is logistically burdensome to perform these after every trauma alert activation. However they need to be performed frequently enough that they become part of the workflow but not burdensome so a decision would have to be made – all level 1s, or 1s and 2s, etc Also, do not just focus on events with poor outcomes Debriefing clinical events with good outcomes can reinforce behaviors that contributed to successful outcome & strengthen team’s familiarity & comfort w/ debriefing
- So what do you talk about. Some with trauma video review programs establish benchmarks for performance that they use to rate whether the resuscitation was successfully conducted. Some examples of benchmarks that are focused on to guide the discussion are: Leader & team roles allocated – 3-4 individuals completing the primary survery, 3 individuals aren’t asking the patient different questions (airway individual, 2 residents at the bedside, leader at the foot of the bed, and performing the exam to complete the primary & secondary survey). Are physical exam findings clearly communicated to recording nurse, is closed loop communication used to provide orders
- For longer debriefings such as larger team debriefing discussing a resuscitation or simulation session this strategy can be used Plus/Delta Pros: easy to remember to perform, can be conducted quickly Cons: avoid generating long lists of mistakes/positives without dissecting the underlying rationale, blame & shame session, What went well? IV access was obtained within 5 minutes What could be changed in future?
- Does not need to be long, needs to be focused and succinct. You are unlikely to address every issue/concern in depth. For workflow integration it cannot last longer than 5-10 minutes. But although it is short, it can still be very effective. If the facilitator (or one group of individuals such as the physicians) is doing all the talking, it’s not a debriefing! Delivery is as important as content!
- Any questions?