Debriefing in the Emergency Department After Clinical Events: A Practical Guide

doi:10.1016/j.annemergmed.2014.10.019

Annals of Emergency Medicine

Volume 65, Issue 6, June 2015, Pages 690-698

https://doi.org/10.1016/j.annemergmed.2014.10.019 Get rights and content

One vital aspect of emergency medicine management is communication after episodes of care to improve future performance through group reflection on the shared experience. This reflective activity in teams is known as debriefing, and despite supportive evidence highlighting its benefits, many practitioners experience barriers to implementing debriefing in the clinical setting. The aim of this article is to review the current evidence supporting postevent debriefing and discuss practical approaches to implementing debriefing in the emergency department. We will address the who, what, when, where, why, and how of debriefing and provide a practical guide for the clinician to facilitate debriefing in the clinical environment.

Section snippets

Case Study

You are working in the emergency department (ED) and a mother rushes in screaming with her pale child. The child is taken to the resuscitation room, intubated, and transferred to intensive care. Your resident asks whether the team should debrief. You have debriefed in simulation but never after an actual resuscitation. You decide to conduct a debriefing. What does debriefing in the clinical setting entail and where should you and your team begin?

Why?

The function of debriefing is to identify areas of optimal and suboptimal performance and then determine ways to improve future team performance. The ultimate focus of debriefing should not be on blaming individuals but on taking a look at all available facts and perspectives that will help improve processes and patient outcomes. The quality of future performance can potentially be improved by incorporating a number of quality improvement processes into the debriefing (Table 2).

For individuals

What Clinical Events Should Trigger a Debriefing in the ED?

Simulation-based education typically includes a structured debriefing, with learning objectives based on the nature of the simulation.11, 19, 20, 21, 22 Conversely, in the ED, the nature and timing of critical events are unpredictable, making the trigger for debriefing a complex decision process.¹³ Standardization of which clinical events to debrief can enable team members to anticipate a debriefing, align departmental goals, and increase debriefing frequency.

Selection of the appropriate

Debriefing Participants

Who should participate in the debriefings? All team members who actively participated in the clinical event should be invited to participate in the debriefing.²⁶ In the study by Mullan et al,⁵ multiple team members were often present, including the physician leader (98%), primary nurse (95%), respiratory therapist (83%), secondary nurse (83%), charge nurse (81%), and resident (70%); other members included pharmacists, social workers, translators, and patient advocates. Participation by all team

How?

Debriefing should include a friendly atmosphere, open-ended questions, honest dialogue, and identification of behaviors or perceptions that lead to improved outcomes.¹ Postevent debriefing literature is scant compared with the simulation literature. Although similar theories may apply to both, there are unique aspects to debriefing in each setting that are still being worked out.5, 7, 8, 11, 16, 21, 30, 33, 34 Careful selection of the appropriate debriefing method(s) should be considered when

When?

Finding the time to debrief is often challenging. The timing of debriefing has been classified with temperature adjectives, termed “hot” (immediately after the event), “warm” (minutes to hours after an event), and “cold” (days to weeks after an event) debriefings.⁵² When feasible, some form of debriefing should be conducted as soon as possible after an event.²³ Advantages of hot and warm debriefings are that the entire team is usually available, a greater variety of clinical staff is typically

Where?

With most ED space already designated for 1 or more functions, finding an ideal location to debrief events can be challenging.27, 53, 54 The value of debriefing in the space where an event occurred will depend on the objectives of the debriefing. Debriefing in the actual space helps teams to evaluate factors that may otherwise be missed by debriefing in a separate space, including the setting, resources, and processes of an event.⁵⁵ Also, a team can practice technical skills with the same

Postdebriefing

Documentation of key findings and discussion points raised in a debriefing can help with follow-up and promote accountability in a clinical debriefing program.²⁶ Whatever recording method is used (eg, paper, video), it should coordinate with existing quality improvement processes. The recording methods should also be reviewed with the hospital’s medicolegal team to ensure that proper safeguards are in place to protect teams from medicolegal liabilities. Without such protections, teams might

Conclusions

Although the clinical environment is more chaotic than a classroom setting, there are unique learning opportunities in the clinical setting. Structured debriefing can help teams to improve future clinical care and is an important tool for emergency physicians to have in their management toolbox to help them run a successful ED. This article serves as a practical guide to help practitioners start debriefing after clinical events and help stakeholders to initiate debriefing programs in their ED.

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En las últimas décadas, la preocupación por la seguridad del paciente, las metodologías docentes centradas en el participante, la experiencia y la reflexión han llevado al desarrollo de fórmulas de comunicación que facilitan el aprendizaje. Así, el aprendizaje basado en simulación clínica ha demostrado su eficacia pedagógica acercando al participante a la realidad y a la experiencia sin riesgos. En esta metodología, en la fase de debriefing y junto a un facilitador cualificado, el participante puede tomar consciencia y generar aprendizajes transferibles a la vida real. El coaching como herramienta de acompañamiento a la consecución de objetivos, en su estructura conversacional similar al debriefing aporta herramientas de apoyo al facilitador y al participante. El presente trabajo tiene como objetivo, presentar los componentes y estructuras del debriefing y el coaching, así como proponer la incorporación de algunos elementos del coaching al proceso del debriefing, tanto para el participante como para el facilitador. Se presenta un marco teórico de descripción, fases y estructuras del debriefing y del coaching. Seguidamente se realiza una propuesta de un modelo de debriefing apoyado en elementos del coaching. Y finalmente se aportan conclusiones y recomendaciones centradas en las competencias que el facilitador puede incorporar desde este modelo.
In recent decades, concerns for patient safety, participant-centered teaching methodologies, experience, and reflection have led to the development of communication formulas that facilitate learning. Therefore, learning based on clinical simulation has demonstrated its pedagogical effectiveness, bringing the participant closer to reality, and to a risk-free experience. In this methodology, in the debriefing phase and along with a qualified facilitator, the participant can become aware and generate learning outcomes that can be transferred to real life. Coaching as a tool to accompany the achievement of objectives, in its conversational structure similar to debriefing, provides support tools for the facilitator and participant. The objective of this work is to present the components and structures of debriefing and coaching, as well as to propose the incorporation of some elements of coaching into the debriefing process, both for the participant and the facilitator. A theoretical framework of description, phases, and structures of debriefing and coaching is presented. Next, a proposal for a debriefing model supported by elements of coaching is made. And finally, conclusions and recommendations focused on the competencies that the facilitator can incorporate from this model are provided.
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Through a modified Delphi methodology, we developed a standardized consensus-based debriefing tool. Eleven pediatric GH education experts were recruited. Experts were individuals with leadership experience in GH education who demonstrated academic engagement by either primary or senior authorship of a publication or relevant presentation at a conference. The expert panel (EP) completed 4 surveys that were amended after each round based on qualitative data, which was assessed for emergent themes. In the final round, the EP rated each consensus recommendation in importance using a 4-point Likert scale.
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An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years.
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: Supervising editor: Daniel A. Handel, MD, MPH

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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: Continuing Medical Education exam for this article is available at http://www.acep.org/ACEPeCME/.

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The practice of emergency medicine/conceptsDebriefing in the Emergency Department After Clinical Events: A Practical Guide

Section snippets

Case Study

Why?

What Clinical Events Should Trigger a Debriefing in the ED?

Debriefing Participants

How?

When?

Where?

Postdebriefing

Conclusions

Resuscitation

Resuscitation

Semin Perinatol

Jt Comm J Qual Patient Saf

Anesthesiol Clin

Clin Sim Nurs

Resuscitation

J Emerg Med

Resuscitation

Anesthesiol Clin

The role of debriefing in simulation-based learning

Simul Healthc

Island Victory—The Battle of Kwajalein Atoll

Facilitating LOS Debriefings: A Training Manual. Moffett Field: Part 1: An Introduction to Facilitation

Death on the table—some thoughts on how to handle and anaesthetic-related death

Anaesthesia

Do team and individual debriefs enhance performance? a meta-analysis

Hum Factors

Improving in-hospital cardiac arrest process and outcomes with performance debriefing

Arch Intern Med

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes

Crit Care Med

Debriefing for technology-enhanced simulation: a systematic review and meta-analysis

Med Educ

Part 16: education, implementation, and teams: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

Circulation

Postresuscitation debriefing in the pediatric emergency department: a national needs assessment

CJEM

National survey of pediatric emergency medicine fellows on debriefing after medical resuscitations

Pediatr Emerg Care

Research regarding debriefing as part of the learning process

Simul Healthc

Principles of Topological Psychology

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department

BMJ Qual Saf

Simulation to assess the safety of new healthcare teams and new facilities

Simul Healthc

Technology-enhanced simulation for health professions education: a systematic review and meta-analysis

JAMA

Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial

JAMA Pediatr

Evolution of the pediatric advanced life support course: enhanced learning with a new debriefing tool and web-based module for pediatric advanced life support instructors

Pediatr Crit Care Med

The practice of emergency medicine/concepts
Debriefing in the Emergency Department After Clinical Events: A Practical Guide