The process of debriefing has been shown to play an important role in identifying and addressing human factors in the healthcare setting as they pertain to patient safety . It has also been shown to be recognized as an important aspect of patient care, quality improvement, and medical education by healthcare providers, but is difficult to implement into the clinical setting due to poor standardization, beliefs surrounding a certain degree of training needed to facilitate appropriate debriefings, as well as workload demands and time constraints. Furthermore, the highly varied environments in which PRD has been studied, ranging from medical education and simulation, to evaluation and assessment, to clinical environments which differ in workflow and logistical constraints further compound the difficulty of implementing a post-resuscitation debriefing culture into pediatric acute care environments, despite published need and motivation to do so . The use of PRD tools have been cited as potential solutions to address the barriers towards implementing PRD practices, however, lack of direct comparison between PRD tools currently makes it impossible for institutions to adopt an evidence-based PRD tool that meets the needs of their team and clinical environment. The literature recommends focusing on core principles including clarify the objectives for debriefing as this has the potential to help in identifying both the method(s) and outcomes measures of importance when selecting debriefing tools and methods .
As a result, the objective of the study was to directly compare two PRD tools, DISCERN and PCP, in an effort to determine which tool is the most effective to facilitate post-critical event debriefs in acute care settings within a tertiary care children’s hospital. The two debriefing tools, DISCERN and PCP, were used in four different settings (NICU, PICU, ED and pediatrics Code Blue team) with multidisciplinary teams including but not limited to physicians, nursing staff, pharmacists, and medical learners of various stages, with the goal of facilitating a debriefing discussion following a critical event. The results of this study provide novel and fascinating insight into the role of debriefing in a clinical setting, the types of events and environments in which debriefs are requested by members of an interdisciplinary healthcare team, as well as the components of a PRD tool that contribute towards meaningful and efficient debriefings.
Given that a formal PRD process did not exist at our institution prior to this study, the process of PRD had to be implemented in order to carry out this study. The process of this implementation was assessed with regards to timing of training employees, resources, time of debriefings themselves, and other logistical considerations for implementation of a PRD tool. It was previously been described that the majority of healthcare workers believe that some formal training is required for the process of PRD and that time of debriefings are a barrier to PRD . Training was easily carried out through the hospital wide continuous quality improvement initiative by Nurse Educators and Quality Nurses of the various clinical units and also with reminders at daily safety huddles at clinical units. Making PRD tools easily accessible to team members was also found to be feasible by having physical copies attached to code carts and in an envelope outside the resuscitation room in the ED. With regards to length of the debriefings themselves, the average duration of debriefings using PCP was found to be 18.1 min, while DISCERN debriefings lasted an average of 11.1 min, which constituted a significant difference between PRD tools, so this may be factor to consider when choosing a debrief tool. Overall, the average time of all debriefings was quite short, lasting an average of 14.2 min, and reinforces that PRD is feasible and realistic for acute clinical areas.
Although there were a wide variety of distressing situations which triggered debriefs captured by this study, including resuscitations and unanticipated outcomes resulting in the death of patients, the majority of debriefs were triggered in response to a patient death regardless of whether it was expected or not. Both tools were found to be useful in providing emotional support as well as identifying areas for improvement on individual, team, and systems levels in these scenarios. This speaks to the need for teams to have access to some kind of format for debrief in healthcare settings for emotional wellbeing of team members as well as to support quality improvement and patient care. Team members are astute when it comes to recognizing when debriefing is required. Creating ease of access to debrief resources, formats, and/or PRD tools can help facilitate a culture where debriefs are incorporated into daily practice.
Despite the differences that exist between the content and structure of DISCERN and PCP, the only significant differences in user-rated experience were found to be in the level of emotional support that the tool seemed to help foster as well as the support of clinical education.
Notably, the majority of debriefs, using either tool, were triggered in the Emergency Department in response to a critical event deemed to require debriefing by a team member involved in the case. The ED environment poses particular challenges with regards to practical considerations during debriefs including significant time restraints, the potential for a wide variety of triggering events including novel scenarios never previously encountered by a team, as well as a team that is likely to change more frequently than other departments, thus posing additional challenges when it comes to debrief comfort and emotional support required. Despite demanding, high acuity, and fast-paced environments, both tools were found to be equally easy to use, as well as found to equally support the debrief process, identify new opportunities for improvement, and contribute to participant comfort when debriefing. This lends further support to the idea that regardless of the tool, some kind of debrief framework is helpful to teams in both encouraging debriefing and in helping to facilitate the process and yielding valuable results.
The DISCERN tool, while helpful with identifying what went well and what could be improved, actually did not address the team members’ overall wellbeing following the event. In reviewing the comments from the DISCERN tool, there were no responses commenting on how the staff were doing post-event. Team support was identified multiple times as a strength, but without any further details describing what exactly those elements of team support were.
The PCP specifically asked how the responders were doing after the event and what would be needed the healthcare professionals to safely return to work. These questions highlighted emotions such as “tired”, “proud”, “hard to go back to work when it’s non-acute things after [resuscitation]” and “emotionally okay”. It also helped to elicit actionable items for post-resuscitation care including “more reasonable clinical load when carrying the front-line pager” or “check-in with each other…”. It not only provided a safe environment for team members to debrief on their emotions following a high-stakes event, but also an opportunity to discuss how staff support during and after these events can be improved.
Thematic analysis revealed that while the DISCERN tool’s broad questions (ie. What went well? What could be improved?) allowed healthcare professionals to reflect on the event, it did not always fully explore some of the themes raised. It did, however, give the responders a space to speak about anything that arose that they felt the need to discuss post-event. PCP provided a more organized approach to the debrief and was able to direct the conversation to key areas of debriefing. There was the opportunity to discuss what went well during the critical event, but the areas of improvement were further broken down. Specific questions allowed for comment on the availability of interventions, medications and equipment in addition to a question about general improvement. Although the answers to the specific prompts were briefer, they were more focused and allowed for the pulling of actionable items for improvement in the response of critical events. PCP importantly also contains a section on the mental and emotional wellbeing of healthcare professionals post-event. This is something that may get missed in a debrief as healthcare professionals focus on what went well and what could be improved. This was evidenced in the DISCERN tool as there were no comments pertaining to how the healthcare professionals were doing after the event or what could be added to support them post-critical events.
With regards to the thematic analysis, a very common theme identified in both the DISCERN and PCP surveys was the functioning of the responders as a team during the critical event. Team dynamics was both in reference to communication throughout the event, as well as leadership and role clarity. Again, in both tools this theme was identified as a strength in some events and as an area for improvement in others. Although themes were both identified as a strength in one scenario, and then as an area of improvement in the next, it is important to note that the scenarios that were being debriefed were not standardize and neither were the responding healthcare professions. This resulted in different strengths and areas of improvement being described in each of the debrief tools. It was difficult to identify consistent themes of strengths or weakness due to the variation of location and type of critical event in addition to different healthcare providers responding to said event.
Additional themes, including equipment availability and preparation were emphasized as being very important to a resuscitation across the debriefing tools. This was again brought up as both a strength and as a weakness dependent on the scenario being debriefed. Although, the DISCERN tool also provided specific actionable items for equipment malfunctions and proposed equipment changes, it is sometimes lost in the other comments or not fully explored. It may be due to the debrief documenter only writing down key works “glidescope stylet” or “delay of urgent x-ray”, but never explored any further. Again, the broad nature of the question “what could be improved?” as used in the DISCERN tool provides a blank slate for possible responses. It was noted that often it actually resulted in vague and non-descriptive answers.
This is contrasted with the PCP tool, which used very specific questions as part of the debriefing process. It specifically asked both what interventions the team wished they had offered as well as whether the team was satisfied with the availability of the medication and equipment. This resulted in responses such as “room was set up appropriately… [but] computer to chart would be helpful” or “curved [laryngoscope] blade would have been helpful”. This is helpful in providing actionable items for improvement on the overall resuscitation process. If the debrief tool is to be used for identification of areas of improvement, providing specific questions in order to both lead the discussion and provide an organized documentation may prove to be useful.
The primary objective of this study was to assess user preference with regards to utility of two PRD tools, DISCERN and PCP, based on personal, situational, environmental, and team-based factors, with the ultimate goal of this initiative being to institute a children’s hospital-wide debriefing tool for PRD. Secondary aims included determining whether there were differences in the quality, subject matter, and types of feedback garnered from these different tools and potential implications on quality improvement and patient safety. Given the dynamic nature of a clinical environment, there were a variety of factors that could not be controlled in this study, including how long after the critical event the debriefing itself took place, which team members were present at the debrief, the space in which the debrief took place, and the amount of time that was available for the debrief to take place, which limits the standardization of the debriefing process. Furthermore, given the nature of events being discussed, there was content in the debriefs that was not included in analysis to maintain patient confidentiality. Finally, although one of the secondary aims of the study was to assess the implications of the debriefing on quality improvement and patient safety, which was done by comparing responses between PRD tools, whether or not identified areas of improvement were translated into practice and the ease of implementing these changes was not assessed through this study.
In medicine, the wellbeing of the medical team or responding team is not often thought about as being critical to the response of a resuscitation. The goal of a debriefing tool should be two-fold: both to identify the strengths and areas of improvement of the event, but also to allow the responding staff to express how they are feeling post-event. As a result, it is recommended that some form of debrief tool be made available and accessible to healthcare providers to help facilitate these discussions. The implementation of a structured PRD tool can remove many of the barriers to the process of debriefing and thus help facilitate discussion, improve emotional support and comfort for participants, and lead to more consistent debriefs across teams and settings. This study found that a PRD tool is feasible to implement with respect to both formal training of healthcare workers on the use of each tool and the purpose and importance of PRD as well as the time of debriefings themselves, both of which have been previously identified as barriers towards implementing PRD . Based on the results of this study, it is recommended that an institution or setting specific PRD tool be chosen based on institution and team values and preferences and demands including team dynamics, constraints of the environment or setting such as time restrictions, and especially the degree of emotional support deemed to be valuable from a quality improvement and patient safety perspective. Other options including having a variety of PRD tools available with the option for teams to choose a debrief tool to use based on the triggering situation such as tools available for times when more emotional support is deemed necessary such as after an unexpected death versus times when more quality improvement/patient safety ideas are required such as after an unexpected outcome.