An Evaluation of a New Debriefing Framework

ORIGINAL ARTICLE

An Evaluation of a New Debriefing Framework: REFLECT Lauren E. Zinns, MD, FAAP,* Paul C. Mullan, MD, MPH,† Karen J. O'Connell, MD, MEd,‡ Leticia M. Ryan, MD, MPH,§ and Angela T. Wratney, MD, MHSc||

Background: Postresuscitation debriefing (PRD) is recommended by the American Heart Association guidelines but is infrequently performed. Prior studies have identified barriers for pediatric emergency medicine (PEM) fellows including lack of a standardized curriculum. Objective: Our objective was to create and assess the feasibility of a timelimited, structured PRD framework entitled REFLECT: Review the event, Encourage team participation, Focused feedback, Listen to each other, Emphasize key points, Communicate clearly, and Transform the future. Methods: Each PEM fellow (n = 9) at a single center was a team leader of a pre-intervention and post-intervention videotaped, simulated resuscitation followed by a facilitated team PRD. Our intervention was a 2-hour interactive, educational workshop on debriefing and the use of the REFLECT debriefing aid. Videos of the pre-intervention and post-intervention debriefings were blindly analyzed by video reviewers to assess for the presence of debriefing characteristics contained in the REFLECT debriefing aid. PEM fellow and team member assessments of the debriefings were completed after each pre-intervention and post-intervention simulation, and written evaluations by PEM fellows and team members were analyzed. Results: All 9 PEM fellows completed the study. There was an improvement in the pre-intervention and post-intervention assessment of the REFLECT debriefing characteristics as determined by fellow perception (63% to 83%, P < 0.01) and team member perception (63% to 82%, P < 0.001). All debriefings lasted less than 5 minutes. There was no statistical difference between pre-intervention and post-intervention debriefing time (P = 1.00). Conclusions: REFLECT is a feasible debriefing aid designed to incorporate evidence-based characteristics into a PRD. Key Words: REFLECT, debriefing, debriefing guide, postresuscitation debriefing, simulation, pediatric emergency medicine fellowship (Pediatr Emer Care 2017;00: 00–00)

encourage the use of routine debriefing.5,6 Reflection is a valuable form of debriefing used by interprofessional teams to emphasize what went well, identify performance gaps, discuss areas for improvement, and consolidate knowledge and skills into specific action items with the goal of improving system processes and team function.7–10 Several recent studies highlight the significance of debriefing in the clinical setting independent of the resuscitation outcome.11–17 Most studies focus on cold debriefing, which occurs days to weeks after an event and allows team members to learn from performance data. Hot debriefing, in contrast, occurs shortly after the event and provides an opportunity for team members to reflect on their actions, suggest improvements to the delivery of care system, and learn from their resuscitative efforts.14,15 By encouraging teams to regroup and debrief immediately after a stressful event, members benefit from the discussion and patient outcomes may ultimately improve.14–17 Despite the benefits of debriefing, there remains little consensus on the optimal debriefing model, framework, or application to the clinical environment.7,8,12,18 Furthermore, results of a national needs assessment survey on debriefing practices showed that pediatric emergency medicine (PEM) fellows are expected to lead medical resuscitations, yet few receive education on how to effectively lead a team PRD.19 Our research team created an educational intervention and cognitive aid entitled REFLECT to help fellows facilitate PRD. The REFLECT mnemonic stands for Review the event, Encourage team participation, Focused feedback, Listen to each other, Emphasize key points, Communicate clearly, and Transform the future. REFLECT was designed to be both efficient and effective in an emergency department setting.

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Creation of the REFLECT Guide

From the *Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY; †Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, VA; ‡Division of Emergency Medicine, Children's National Medical Center, Washington, DC; §Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and ||Division of Critical Care Medicine, Children's National Medical Center, Washington, DC. Disclosure: The authors declare no conflict of interest. Reprints: Lauren E. Zinns, MD, FAAP, Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1149, New York, NY 10029 (e‐mail: [email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pec-online.com). Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161

Our group of debriefing experts performed a literature search on PubMed using the search terms debriefing and postresuscitation debriefing from 2007 to 2012 to find recent articles published on team debriefing. We collected 50 research articles pertaining to debriefing and selected key recurring themes in the literature. Each researcher read the articles independently, and we decided as a group on a list of the most significant themes. Our objective was to create: (1) a cognitive aid to guide the facilitator through a series of domains relevant to critical events and team resuscitation in the emergency department, (2) a framework that would foster active participant involvement in the PRD; and (3) an efficient resource that could be employed typically in 10 minutes or less. We created the REFLECT mnemonic (Table 1) to serve as a guide for providers when performing a team PRD. Our team of 5 debriefing experts included 3 PEM attendings (L.R., K.O., P.M.) and 1 pediatric intensive care unit attending (A.W.), each with substantial experience and training in debriefing interprofessional teams in both simulated and actual patient care environments, and 1 third-year PEM fellow (L.Z.). We had a combined total of 54 years of experience with clinical debriefing before the study. We pretested the cognitive aid and simulation scenarios on a focus group of pediatric intensive care unit fellows,

ostresuscitation debriefing (PRD) allows providers an opportunity to analyze their thoughts and actions, identify knowledge deficits, and, ultimately, improve future performance.1 Debriefing has been associated with improved cardiopulmonary resuscitation quality and better neurologic outcomes.2 Debriefing is also linked to reduced provider stress3 and higher perceived adequacy in leading difficult resuscitations.4 Organizations including the American Heart Association and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine both

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TABLE 1. REFLECT: A Debriefing Guide The Mnemonic Highlights Key Aspects of a PRD R = Review the event State a one-line summary of the patient's presentation E = Encourage team participation Elicit feedback from the team members: what went well and what could have been improved F = Focused feedback Targeted feedback to the team L = Listen to teach other Foster a safe learning environment E = Emphasize key points Highlight take-home messages from the resuscitation C = Communicate effectively Use common language with shared expectations T = Transform the future Tips for improving future resuscitations

PEM attendings, and research team members from the intensive care unit and emergency departments for the purpose of content review, realism of the scenarios, and application of PRD in a busy clinical setting. We made iterative changes to the scenarios based on focus group feedback until consensus was achieved.

METHODS The pilot intervention was conducted at Children's National Medical Center in Washington, D.C. a large urban pediatric academic center with a level-1 trauma center and a 3-year PEM fellowship program. At the time of the study, there were 10 PEM fellows in training. We invited 9 of the 10 PEM fellows in training to participate in the study; the remaining fellow designed and conducted the study and, therefore, did not participate as a subject. Participants included 4 first-year PEM fellows, 3 second-year PEM fellows,

and 2 third-year PEM fellows. We conducted this study within a 4-week training period, from November to December 2012, to limit the influence of training exposures on debriefing experience. The institutional review board at Children's National Medical Center approved the study. Our objective was to assess the feasibility of a debriefing aid designed to guide PEM fellows in facilitating a team PRD. After informed consent, all 9 of the PEM fellows independently led a resuscitation team consisting of 2 PEM nurses and a pediatric resident during a 10-minute high-fidelity simulated resuscitation, followed immediately by a fellow-led team PRD. Each fellow was evaluated at baseline and again after an educational intervention that involved using the REFLECT cognitive aid. The simulated case involved a 4-month-old infant in cardiopulmonary arrest with active cardiopulmonary resuscitation (Figure 1, Supplemental Digital Content 1, http://links.lww.com/ PEC/A162). Pediatric emergency medicine fellows were encouraged to use the REFLECT aid as part of their team's PRD. Our research team designed and conducted a 2-hour interactive workshop to teach PEM providers how to lead a PRD. All 9 PEM fellows participated in the intervention. This session highlighted the history and significance of debriefing, as well as various debriefing methods, and introduced the REFLECT debriefing cognitive aid.1,3,4,20–26 Participants learned the importance of each component of REFLECT, creating a safe, nonpunitive environment to foster team reflection after a simulated scenario of an infant in hypovolemic shock. Each participant received a laminated card with a description of the REFLECT guide designed to be worn behind their ID badge (Fig. 1). Within 2 weeks of this intervention, each PEM fellow independently led another 10-minute simulated resuscitation with 2 PEM nurses and a pediatric resident. The simulated scenario was similar in the degree of critical illness of the patient but involved a 6-month-old full-term infant presenting to the emergency department with unstable ventricular tachycardia who quickly progressed to cardiac arrest after initial resuscitative efforts (Figure 2, Supplemental Digital Content 2, http://links.lww.com/PEC/A163). All simulations were video-recorded and randomly assigned numbers from 1 to 18 by the simulation technician. Each PEM

FIGURE 1. REFLECT debriefing guide.

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Evaluation of a New Debriefing Framework: REFLECT

FIGURE 2. Fellows' evaluation of debriefing process.

fellow anonymously completed a written evaluation regarding their perceived performance as the debriefing facilitator, and each team member completed the same regarding their perceived clinical performance (Figs. 2, 3). Two reviewers (P.M., L.R.) were blinded to the pre-intervention versus post-intervention status; each reviewer independently reviewed the videos and analyzed the data using a teamwork assessment tool, the Team Emergency Assessment Measure.27 Data were reviewed until consensus was achieved. Two additional investigators (K.O., A.W.) were blinded to the pre-intervention or post-intervention status of the debriefing videos; each reviewer independently assessed whether the 7 components of the REFLECT mnemonic were demonstrated. We collected data from the written evaluations completed by fellows and team members and identified prevalent content themes relating to the REFLECT mnemonic using qualitative thematic analysis methodology. Wilcoxon signed-rank tests were performed on the REFLECT themes that were identified in the simulations before and after the intervention. McNemar tests were used to compare individual pre-intervention and post-intervention REFLECT themes. We considered a P value of less than 0.05 significant. We analyzed our data with SAS (version 9.4; Cary, NC).

RESULTS Qualitative Results: Written Comments from Survey All 9 PEM fellows completed the pre-intervention simulation, debriefing workshop, and post-intervention repeat simulation. Fellows commented that team members worked well together in the simulated resuscitation using closed loop communication in a calm, organized fashion. While all fellows thought the simulated resuscitations were realistic, they indicated that leading the simulated

resuscitation was “stressful.” They felt the scenarios to be particularly difficult due to “time constraints” of a 10-minute resuscitation. Fellows felt “comfortable” during the resuscitation when “everyone helped” in a “collaborative” effort. They commented that with “good team dynamics,” “team members responded well” to direction and offered helpful suggestions. Pre-intervention, fellows reported feeling “awkward” and “unsure” of what to say during the PRD. Post-intervention, fellows reported they felt “better” facilitating PRD especially “with feedback from the team.” Team members reported that roles were “well-defined” during the simulated resuscitations. “Periodic check-ins” by the leader using a “shared mental model” were reportedly helpful to allow for a clearly orchestrated plan of care.

Quantitative Results: Analysis of the REFLECT Aid Regarding feasibility of the REFLECT cognitive aid to impact debriefing structure, fellows reported improvement in overall use of the REFLECT aid from 63% to 83% (P < 0.01), but no significant improvement in individual components of REFLECT (Table 2). With the team member responses, there was an improvement in overall use of the REFLECT aid from 63% to 82% (P < 0.001), with significant improvements noted in the “transform the future” component (13% to 69%, P = 0.01; Table 3). Video review assessment found there was no statistically significant improvement in overall (60% to 76%, P = 0.09) or individual components (Table 4). The duration of time spent debriefing was less than 5 minutes for all of the sessions. The median time of preintervention PRD sessions was 2:24 (interquartile range, 1:57–2:50). The median time of post-intervention PRD sessions was 2:06 (interquartile range, 1:42–2:56). There was no statistical

FIGURE 3. Team members' evaluation of debriefing process. © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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TABLE 2. Fellows: REFLECT Components in Debriefing Pre-intervention and Post-intervention R Fellow year 1 1 1 1 2 2 2 3 3

E

F

L

E

C

T

Fellow #

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

7 4 2 9 3 1 8 5 6

X X X X

X X X X X X X X X

X X X X

X X X X X X X X X

X X X

X X X X X

X X X X X X X X X

X X X X X X X X X

X

X X X X

X

X X

X

X X X

P

X X X

N/A

X X X X

1.00

X X X 1.00

X

X X

Post X X X

X X

X X X X

N/A

X X X

X X

1.00

X

1.00

0.25

R indicates Review the event; E, Encourage team participation; F, Focused feedback; L, Listen; E, Emphasize key points; C, Communicate clearly; T, Transform the future.

PRD. Furthermore, our study results found improved content in PRD for all levels of fellows in training, not only the senior fellows. We believe that this finding may be owing to the fact that all fellows had no prior experience with PRD before the onset of the study19 and, therefore, equally benefitted from the intervention and ability to practice debriefing in a safe, simulated environment. We found that, through the use of a short, interactive workshop, we could successfully teach PEM providers how to facilitate team PRD using a practical aid. By providing more structure, we subjectively noticed that the simulated PRD discussions tended to be richer, with more team member engagement, feedback, and emphasis on team-based care and communication with a focus on improving future performance.27,30 Based on a recent national needs assessment survey detecting the lack of formal debriefing training,19 PEM fellows expressed a strong interest in learning how to facilitate a team PRD. As a result of this pilot intervention, fellows' reported a greater level of comfort both initiating and facilitating a team PRD using the REFLECT aid. It is imperative that leaders of multidisciplinary resuscitation teams not only be well trained in the clinical aspects of the care delivery but also be knowledgeable of the importance and

difference between the durations of pre-intervention and postintervention PRD (P = 1.00, Table 5).

DISCUSSION This study served as a pilot trial of a new educational framework designed to teach PEM fellows how to efficiently and effectively conduct a PRD. The mnemonic aid REFLECT highlights the important evidenced-based aspects of a structured debriefing, namely, a review of the event, encouraging team member participation, focused feedback to team members, listening to foster a safe environment, emphasis on key points using clear communication, and tips for transforming future resuscitations.7,9,11–13,18,20,24,25,28–30 Similar to other communication guides or templates, the REFLECT cognitive aid serves as a framework upon which to organize a team PRD. It provides guidance about key aspects to address during the group discussion and can be modified based on experience.7,11,12,18,28 Our results demonstrate a significant difference in use of the REFLECT aid between pre-intervention data compared to the post-intervention data for the fellows and team members. These findings suggest that the intervention was both informative and influential to the team by providing an organized framework for

TABLE 3. Team Members: REFLECT Components in Debriefing Pre-intervention and Post-intervention R Fellow year 1 1 1 1 2 2 2 3 3

Fellow # 7 4 2 9 3 1 8 5 6

P

Pre

E

F

Post

Pre

Post

Pre

X X X X X X X X X

X X X X X X X X

X X X X X X X X X

X X X X

X X

0.13

1.00

L Post X X X X

X X

X X X 0.45

E

Pre

Post

X X X X X X X X X

X X X X X X X X X 1.00

Pre

C

T

Post

Pre

Post

X X X X X

X X

X X X X X X X X X

X

X X X 0.13

X X X X X X 0.50

Pre

Post X X X X

X 0.011


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Evaluation of a New Debriefing Framework: REFLECT

TABLE 4. Video Analysis: REFLECT Components in Debriefing Pre-intervention and Post-intervention R Fellow year

Fellow #

1 1 1 1 2 2 2 3 3

7 4 2 9 3 1 8 5 6

Pre

E Post

X

X X 0.63

L

E

C

T

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

X X

X X X X X X X X X

X

X X X X

X X X X X X X X X

X X X X X X X X X

X

X X

X X

X X X X

X

X X X X

X X X X

X X X

X X X X

X X X X

X X X

P

F

Pre

X X X X X X

X X

X X

1.00

X X 1.00

N/A

1.00

1.00

Pre

Post X X X X X

0.06


appropriately trained as facilitators in PRD, so that process improvement and patient safety are optimized. Through the use of debriefing aids such as REFLECT, providers can effectively reflect-on-action in an organized way to facilitate a multiprofessional team PRD.9,25 Larger studies will be necessary to evaluate how the REFLECT cognitive aid facilitates effective and comprehensive PRD after actual patient resuscitations.

Limitations There are several limitations to this study. The simulation events were specifically designed to replicate clinical scenarios the PEM fellows may encounter in an emergency setting. First, the fellows reported that the situations were realistically challenging; however, the simulated team structure with fewer role-based providers and a 10-minute resuscitation time limit may have added additional stress to perform critical time-sensitive tasks. Second, survey questions may have been subject to reporting bias by participants' knowledge of pre-intervention and post-intervention status. Third, this pilot study was performed at a single center in a simulated environment and may have limited generalizability to other clinical settings. Fourth, the video reviewers were blinded TABLE 5. Duration of PRD Sessions Facilitated by Pediatric Emergency Medicine Fellows Pre-intervention and Post-intervention with a Structured, Interactive Debriefing Curriculum and REFLECT Guide

Fellow 1 2 3 4 5 6 7 8 9

Pre-Intervention Debriefing Time (min: s)

Post-Intervention Debriefing Time (min: s)

1:46 2:57 1:31 1:58 1:57 2:50 3:02 2:30 2:24

1:36 3:39 1:21 2:06 2:35 4:13 1:42 1:49 2:56

There is no statistically significant difference between the length of pre-intervention and post-intervention debriefing sessions (P = 1.00).


to whether the PRD was performed before or after the educational intervention. The fellows did not physically use or refer to the REFLECTaid during their PRD, yet it remains possible that the video analysis could not be completely blinded to the pre-intervention and post-intervention status of the fellow. Finally, our study results detected improvement in only 1 REFLECT component before and after the educational intervention (transform the future for team members only). This pilot study was not powered to find significance in each of the REFLECT components given the small sample size of only 9 PEM fellows. Future studies using a larger sample size might allow for a more robust analysis of the debriefing aid's effect on training and conducting PRD after critical events.

CONCLUSIONS Postresuscitation debriefing is an important skill for PEM providers to learn. The succinct REFLECT cognitive aid can provide a structured framework for PRD in the emergency department. ACKNOWLEDGMENT The authors would like to acknowledge Xuemei Zhang, MS, Senior Biostatistician at The Joseph Stokes Jr. Research Institute at The Children's Hospital of Philadelphia, for her help with the statistical analyses performed in this study. Also, the authors thank Megan Crandell, RN, Children's National Medical Center, Washington, D.C.; Emily Dorosz, RN, Children's National Medical Center, Washington, D.C.; Quiana Hart, RN, Children's National Medical Center, Washington, D.C.; Robert Kavanagh, MD, Penn State Hershey Children's Hospital, Hershey, PA and Matthew Schoenherr, MS, Children's National Medical Center, Washington, DC. Without their help, this project would never have been feasible. REFERENCES 1. Rudolph JW, Simon R, Raemer DB, et al. Debriefing as formative assessment: closing performance gaps in medical education. Acad Emerg Med. 2008;15:1010–1016. 2. Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. Crit Care Med. 2014;42: 1688–1695. 3. Burns C, Harm NJ. Emergency nurses' perception of critical incidents and stress debriefing. J Emerg Nurs. 1993;5:431–436. 4. Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med. 2007;35:1668–1672.

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