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CAEP FEI | Critical Incident Stress Management

In Featured Education Innovations (FEI) by Andrew DixonLeave a Comment

Glenn is an Emergency Department RN who has basically seen it all through his fifteen years of practice. One day, a teenager is rolled into the trauma bay in cardiac arrest after a horrific car crash. Despite the team’s best efforts, the resuscitation fails and the teenager dies. Afterwards, Glenn is shaken and wants to talk. The trauma team leader organizes a debrief but doesn’t seem like she knows what to say, and there’s a lot left unsaid. Glenn can’t get the case out of his mind for the rest of the shift and doesn’t know who to talk to. 

In Emergency Medicine, unexpected tragedies are an expected part of our specialty, and a skilled debrief session can be as important for the team as the patient care delivery itself. This Feature Educational Innovation (FEI), titled “Critical Incident Stress Management – TASK Defusion” on May 15, 2015 and answers the question: “Can we develop a practical debriefing tool to help structure team debriefing after a critical incident?” A PDF version is available here. A CAEP cast is available here.

Background

Physicians are repeatedly exposed to critical incidents throughout their training and practice, which can lead to increased burnout, decreased empathy and suboptimal patient care. Physicians are often asked to facilitate informal debriefing sessions after critical incidents in the clinical setting. However, little is known about the facilitating physicians’ training in debriefing or what debriefing methods are effective.  In critical incident terms, what emergency physician participate in is more accurately called “defusion,” which is a less formal, day-of-the-incident process designed to assure the person or people involved that their feelings are normal, to tell them what symptoms to watch for over the short term, and to offer them knowledge of where to seek help if they are having difficulty. Defusion is designed to assist individuals in coping in the short term and address immediate needs.

Needs Assessment

To assess the needs of learners a national survey was distributed by email to all Canadian emergency medicine residents and program directors. Sixty-two percent of respondents had participated in a debriefing session and 25% had led one or more debriefing sessions. Using a Visual Analogue Scale (VAS) of 1-10 (1= “not at all” and 10 = “very much”), participants scored the usefulness of debriefing sessions for the team and the individual as 7.3/10 (CI 95% ± 0.42) and 6.5/10 (CI 95% ± 0.57) respectively. Respondents scored a mean of 7.6 (CI 95% ± 0.45) for the importance of the skills needed to lead a session, which is in contrast to their level of preparedness being reported as 4.2/10 (CI 95% ± 0.53).
This large gap between the perception of the training provided and the perceived importance of training indicated that a need exists to broaden this aspect of training within emergency medicine.

The Innovation

In response to the needs assessment, we developed a simplified format for conducting a 10-15 minute debriefing/defusion session in the emergency department. It involves 4 phases:

TASK DEFUSION

  • Introduction – discussion of who is present, roles and expectations of debriefing.
  • Management Phase – covers important topics in medical case management, answers questions from the team about why and how decisions were made.
  • Reaction Phase – asks team members to share their reaction to the situation. For example: “If you had the power to erase one single aspect, without changing the outcome, what would you most want to eliminate from this experience?”
  • Teaching Phase – Assure that stress is a normal reaction to an abnormal event.     Give basic strategies for coping, such as:
    • Talk to people
    • Eat and sleep normally
    • Exercise
    • Do something nice for yourself
This method was taught during a 4 hour workshop, including PGY 1-5 emergency medicine residents. There was a short didactic introduction of the method with example questions and methods of transition between the phases. Then there was a stop/start group practice with interruptions for questions and discussion. This was followed by residents participating in smaller group mock debriefings (each resident having an assigned role) that were observed by a trained facilitator. The whole group then met back to discuss the experience.

Limitations

Although the workshop has only been performed once, the resident feedback was excellent. They found the session very practical and useful. We intend to survey the residents in a year to see if they are actually using the tool in the “real world.” We are also developing an app that leads a facilitator through the debriefing process.

Can you give us examples of the best and the worst debriefing sessions you have experienced? What made them good or bad?

More About the CAEP FEI

This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers. 

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Andrew Dixon

Andrew Dixon

Andrew Dixon is a pediatrician at the University of Alberta. He has many interests in education, including simulation feedback, fracture management and patient education.
Daniel Ting
Daniel Ting is an Emergency Medicine resident at University of British Columbia. He is the 2017-18 CanadiEM Digital Scholars Fellow and the inaugural Editorial Intern at the Canadian Journal of Emergency Medicine. Daniel leads the “Great Evidence in Medical Education Summary” and "Feature Educational Innovation" series on CanadiEM.
Daniel Ting
- 2 days ago