Debrief while it’s HOT

In Education & Quality Improvement, Featured by Priyank BhatnagarLeave a Comment

A 72 year old male is brought into the resuscitation room with respiratory distress. He has had two days of fever, cough, fatigue and shortness of breath with a known COVID-19 positive case in his household. His past medical history includes well-controlled hypertension and diabetes. His oxygen saturation on 6L nasal prongs is 88% and it is clear he is working hard to breathe. Intubation for oxygenation is apparent and you prepare your team for a protected intubation. During the resuscitation and intubation you encounter communication issues with the team members outside, missing equipment in the airway cart and as team leader you felt unclear about the airway plan from the intubator. Fortunately, the intubation is successful on the first attempt and the patient is safely transported to intensive care. You feel it is important to discuss how the resuscitation went with the rest of the team and wonder how best to debrief the case.

Debrief:

A debrief is a collaborative discussion of the events that have transpired which incorporate each members’ perspective, experience, and thoughts. It provides for an opportunity for self-reflection​1​. As a tool, debriefing is immensely useful in the emergency department and acute care settings to analyze incidents such as resuscitations, near-misses, medical errors, care provision and patient deaths. It also provides an opportunity to reflect on ways to improve future performance and check-in on team members’ well being​2​. A debrief is a collaborative discussion of the events that have transpired which incorporate each members’ perspective, experience, and thoughts. It provides for an opportunity for self-reflection​1​. As a tool, debriefing is immensely useful in the emergency department and acute care settings to analyze incidents such as resuscitations, near-misses, medical errors, care provision and patient deaths. It also provides an opportunity to reflect on ways to improve future performance and check-in on team members’ well being​2​.

There are two main methods of debriefing: cold and hot. Cold debriefing is a longer format of debrief that utilizes tools such as written or verbal presentations​3​. They are dubbed “cold” because they occur within days to weeks of an event, figuratively once the emotions and reactions have had time to “cool.” These debriefs include analysis of data gathered from the event, like defibrillator feedback or video recordings.

While this format provides valuable insights and detailed feedback of events, they have a longer turnaround time for change implementation that has its drawbacks in fast paced care settings. Additionally, since critical incidents occur frequently in acute care settings, debriefs that are soon after an event allow for faster recognition of areas for improvements that can be implemented in following events​3​. Thus, hot debriefs are an ideal format to debrief events in acute care settings.

A hot debrief, which occurs within minutes to hours of the event, and is conducted while emotions, reactions, and impressions are still “hot.” These debriefs include participants in the resuscitation, are voluntary, timed, and facilitated by any member of the team involved in the critical event.* They often take place in patient care areas. Hot debriefs focus on the immediate reactions and emotions of the team in order to identify processes, procedures and safety measures that can be improved upon quickly, and in real time​4​.

*As a physician being redeployed there will be a vast amount of new information of protocols and knowledge to review. Therefore designating another member of the team to act as the debrief lead, such as a senior nurse, resident, or other member of the team can offload some of the cognitive load that you may be experiencing.

Hot Debrief:

A general approach to leading a hot debrief​5​:

  1. Establish the framework for the debrief
    • Provide an invitation, in a non-judgmental manner, to participate in a debrief
    • Time frame (5 -10 minutes)
    • Provide opportunity to return to other clinical work if very pressing
  2. Basic assumption
    • Establish a safe learning environment for team members
  3. Discuss successes (what went well?)
    • Leadership
    • Communication
    • Team dynamic
  4. Discuss challenges (what could be improved upon?)
    • PPE
    • Equipment failure
    • Delay to therapy
  5. Assess prevention of incident (could this have been prevented?)
    • What led up to the event?
  6. Consider if a cold debrief is needed at a future time for this event
  7. Summary
    • Thank all members for participating
    • Make yourself available for individual discussion immediately after and in the future

Debriefing Tools:

Tools and scripts have been created to help facilitators conduct a hot debrief. Attached is an example of a script that can be used during a hot debrief as well as a link to a webinar with further information on how to conduct a hot debrief:

This post was copyedited by @alexsenger

References:

  1. 1.
    Mayville ML. Debriefing: The Essential Step in Simulation. Newborn and Infant Nursing Reviews. March 2011:35-39. doi:10.1053/j.nainr.2010.12.012
  2. 2.
    Rudolph J, Simon R, Raemer D, Eppich W. Debriefing as formative assessment: closing performance gaps in medical education. Acad Emerg Med. 2008;15(11):1010-1016. doi:10.1111/j.1553-2712.2008.00248.x
  3. 3.
    Couper K, Perkins G. Debriefing after resuscitation. Curr Opin Crit Care. 2013;19(3):188-194. doi:10.1097/MCC.0b013e32835f58aa
  4. 4.
    Sweberg T, Sen A, Mullan P, et al. Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative. Resuscitation. 2018;128:181-187. doi:10.1016/j.resuscitation.2018.05.015
  5. 5.
    Maloney C. Critical incident stress debriefing and pediatric nurses: an approach to support the work environment and mitigate negative consequences. Pediatr Nurs. 2012;38(2):110-113. https://www.ncbi.nlm.nih.gov/pubmed/22685873.
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Priyank Bhatnagar

Priyank Bhatnagar

Dr. Priyank Bhatnagar is an FRCPC Emergency Medicine resident at the University of Toronto. His interests include medical education, geriatrics EM and global health. When not in scrubs, he's likely scrounging for a budget travel deal (pre-COVID)
Priyank Bhatnagar

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Arthur Welsher

Arthur Welsher

Arthur is an Emergency Medicine resident at the University of Toronto. His interests include medical education and simulation.
Alia Dharamsi

Alia Dharamsi

Alia Dharamsi is an Emergency Physician at the UHN and St Michael’s Hospital in Toronto. Her interests include simulation, prehospital medicine, and educational innovation. In her spare time you can find her on her bike, in the lake, or on a mountain!
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