ORIGINAL ARTICLE

National Survey of Pediatric Emergency Medicine Fellows on Debriefing After Medical Resuscitations Lauren E. Zinns, MD,* Karen J. O’Connell, MD, MEd,* Paul C. Mullan, MD, MPH,* Leticia M. Ryan, MD, MPH,† and Angela T. Wratney, MD, MHSc‡ Background: Medical resuscitations of critically ill children in the emergency department are stressful events requiring a coordinated team effort. Current guidelines recommend debriefing after such events to improve future performance. Debriefing practices within pediatric emergency departments by pediatric emergency medicine (PEM) fellows in the United States has not been studied. Objective: The aim of this study was to describe the current debriefing experience of PEM fellows in the United States. Methods: A 10-item, anonymous questionnaire regarding debriefing characteristics was distributed to fellows in US Accreditation Council for Graduate Medical Education–accredited PEM programs via e-mail and paper format from December 2011 to March 2012. Results were summarized using descriptive statistics. Results: Of 393 eligible PEM fellows, 201 (51.1%) completed the survey. The 201 respondents included 82 first-year fellows (40.8%), 71 second-year fellows (35.3%), and 48 third-year fellows (23.9%). Ninety-nine percent had participated in medical resuscitations during their fellowship training, yet 88.0% reported no formal teaching on how to debrief. There was wide variability in the format and timing of debriefings. The majority of debriefings were led by PEM attending physicians (65.5%) and PEM fellows (19.6%). Most (91.5%) of the fellows indicated they would like further education about debriefing. Conclusions: The majority of PEM fellows do not receive formal training on how to debrief after a critical event and may have limited experience in leading debriefings. Debriefing training should be considered part of the educational curriculum during PEM fellowship. Key Words: medical resuscitation, debriefing, PEM fellows (Pediatr Emer Care 2015;31: 551–554)

M

edical resuscitations in the emergency department (ED) require providers and teams to make rapid decisions under a tremendous amount of pressure. Poor outcomes and unexpected deaths can be very stressful for the team members involved. Providers may experience intense emotions in their efforts to treat critically ill patients, including feelings of guilt or inadequacy after an unsuccessful pediatric resuscitation1,2 and consideration of alternative professions after experiencing death of a patient.3 Subsequent debriefing has been shown to provide critical reflection that promotes communication and understanding to enhance team performance.4–9

From the *Division of Emergency Medicine, Children’s National Medical Center, Washington, DC; †Division of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD; and ‡Division of Critical Care Medicine, Children’s National Medical Center, Washington, DC. Disclosure: The authors declare no conflict of interest. Dr Zinns is now an attending physician in the Division of Emergency Medicine at The Children’s Hospital of Philadelphia in Philadelphia, PA. Reprints: Lauren E. Zinns, MD, Division of Emergency Medicine, The Children's Hospital of Philadelphia, 34th & Civic Center Blvd, CTRB 9th Floor, Room 9123, Philadelphia, PA 19104 (e‐mail: [email protected]). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161

Debriefing has its origins in the military as an interactive “after-action” review process designed to help participants synthesize what they thought, felt, and did during a critical event and ultimately improve future efforts.10–16 Debriefing promotes a sense of trust and shared responsibility, builds team morale, and helps facilitate difficult discussions.17 The American Heart Association, American Academy of Pediatrics, and the European Resuscitation Council recommend routine use of debriefing in clinical practice.18–20 Despite the perceived benefits, very little is known about the frequency, timing, and leadership roles of actual debriefing practices that occur after medical resuscitations in academic emergency settings in the United States. We surveyed pediatric emergency medicine (PEM) fellows to identify the current practice of postresuscitation debriefing in pediatric EDs. We hypothesized that PEM fellows in the United States have infrequent exposure to and limited comfort with debriefing in emergency settings.

METHODS A 10-item, anonymous, SurveyMonkey (www.surveymonkey. com) questionnaire was created by a group of emergency medicine physician experts to ensure face validity and piloted by 10 of the pediatric critical care fellows at Children’s National Medical Center in Washington, DC (addendum 1). Modifications to the original survey were made based on critical care fellows’ written feedback. The updated questionnaire was distributed to all 69 PEM fellowship program directors of US Accreditation Council for Graduate Medical Education (ACGME)–accredited programs via e-mail from December 2011 to January 2012. Program directors were instructed to e-mail the electronic survey link to all 393 active PEM fellows. Two e-mail reminders were sent to program directors approximately 3 weeks apart. Paper versions of the survey were also distributed to fellows at a national PEM conference in March 2012. Fellows were instructed not to complete the paper questionnaire if they had already completed it online. The survey explored fellows’ experiences with medical resuscitations and the occurrence of debriefings in the ED after such events. A medical resuscitation was defined as “the emergent management of a critically ill patient that may or may not result in death.” Debriefing was defined as “a discussion after a medical resuscitation generally involving 2 or more members of the medical resuscitation team.” Data were gathered anonymously. The only demographic information collected was the respondent’s postgraduate year of fellowship training. Information on the debriefing leaders, participants, and practice was collected. Fellows reported the approximate number of medical resuscitations they had participated in during their training and the frequency and timing of the debriefing sessions and specified whether their PEM program followed a structured debriefing format. Fellows also reported how comfortable they felt leading a debriefing, their prior education in debriefing, and their interest in learning how to debrief effectively. The primary outcome of our study was to determine current debriefing practices of respondents after medical resuscitations in

Pediatric Emergency Care • Volume 31, Number 8, August 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

www.pec-online.com

551

Pediatric Emergency Care • Volume 31, Number 8, August 2015

Zinns et al

TABLE 1. PEM Fellow Participation in Medical Resuscitations by Year of Fellowship Training No. Resuscitations

First-Year Fellows

Second-Year Fellows

Third-Year Fellows

All Fellows

34/82 (41.5%) 23/82 (28.0%) 12/82 (14.6%) 4/82 (4.9%) 8/82 (9.8%) 1/82 (1.2%) n = 82

7/71 (9.9%) 19/71 (26.8%) 9/71 (12.7%) 11/71 (15.5%) 24/71 (33.8%) 1/71 (1.4%) n = 71

4/48 (8.3%) 4/48 (8.3%) 7/48 (14.6%) 6/48 (12.5%) 27/48 (56.3%) — n = 48

45/201 (22.4%) 46/201 (22.9%) 28/201 (13.9%) 21/201 (10.4%) 59/201 (29.4%) 2/201 (1.0%) n = 201

1–5 6–10 11–15 16–20 ≥20 Not applicable Total

the ED. SurveyMonkey and MS Excel 2011 were used for data collection and analysis. The institutional review board at Children’s National Medical Center approved the study contents and methods of survey dissemination. Survey respondents implied consent by completion of the survey.

RESULTS We achieved a 51.1% (201/393) survey response rate with 169 (43.0%) of 393 completed online and 32 (8.1%) of 393 in paper format. The 201 respondents included 82 first-year fellows (40.8%), 71 second-year fellows (35.3%), and 48 third-year fellows (23.9%). According to 2011 to 2012 data released by the American Board of Pediatrics (ABP),21 there were 143 first-year PEM fellows, 137 second-year PEM fellows, and 113 third-year PEM fellows. When comparing expected results based on the ABP data versus our observed results, we found no significant difference between any of the fellowship years (z = 1.05, P = 0.29 for first years; z = 0.11, P = 0.91 for second years; and z = −1.26, P = 0.21 for third years). Pediatric emergency medicine fellows indicated a wide variation in their participation in medical resuscitations (Table 1) and in their estimate of occurrence of postresuscitation debriefing (Table 2). Ninety-nine percent (199/201) had participated in medical resuscitations during their fellowship training, yet almost a third (61/200, 30.5%) indicated they had never participated in a debriefing session afterward. A majority of PEM fellows (167/ 198, 84.3%) estimated that ED resuscitations were followed by a postresuscitation debriefing in 50% or less of the time. When debriefing did occur, it was most often immediately or within 6 hours after the resuscitation (Table 3). The percentage of debriefings was not found to be correlated with the number of resuscitations (Spearman correlation coefficient = −0.076, P = 0.29). A variety of staff was involved in debriefing sessions including PEM attending physicians, PEM fellows, other subspecialty fellows, residents, nurses, technicians, social workers, rabbis/

chaplains, respiratory therapists, trauma surgeons, and anesthesiologists. One respondent indicated family members were also present. The majority of debriefing sessions were led by PEM attending physicians (127/194, 65.5%) and PEM fellows (38/194, 19.6%), although some respondents indicated that debriefing sessions were occasionally led by nurses, residents, social workers, rabbis/chaplains, and/or psychiatrists. When PEM fellows led debriefings, they reported a range of comfort levels (Fig. 1). Of the 199 total respondents, only 31 participants (15.6%) reported feeling very comfortable leading debriefing. There was no significant association between level of comfort and year of training (χ2=4.44, P = 0.11) or level of comfort and number of resuscitations (χ2 =5.76, P = 0.22). There was a significant association between level of comfort and debriefing frequency, with a higher reported comfort level associated with increased frequency of debriefing (χ2 = 12.78, P =0.01). The majority of respondents (173/200, 86.5%) indicated that their fellowship program did not follow a structured format for debriefing. Most of the PEM fellows (183/200, 91.5%) were interested in learning more about debriefing after medical resuscitations.

DISCUSSION This study was designed as a cross-sectional survey to determine PEM fellows’ experiences with medical resuscitations and subsequent debriefing practices in academic EDs in the United States. We found that while PEM fellows participated in medical resuscitations, they reported infrequent postresuscitation debriefing. Almost a third of all PEM fellow respondents had never participated in a debriefing session, indicating no correlation between number of resuscitations and number of subsequent debriefing sessions. Our study results were consistent with previous studies that show medical debriefing to be an uncommon practice in the ED.6,7,10,22–25 Emergency providers have expressed potential barriers to performing routine debriefing in the ED. These include heavy workload, time constraints, and limited spatial availability.24,25

TABLE 2. PEM Fellow Estimates of Occurrence of Postevent Debriefing After Medical Resuscitations in the ED by Year of Fellowship Training % Occurrence 0 25 50 75 100 Total

First-Year Fellows

Second-Year Fellows

Third-Year Fellows

All Fellows

16/79 (20.3%) 31/79 (39.2%) 18/79 (22.8%) 9/79 (11.4%) 5/79 (6.3%) n = 79

24/71 (33.8%) 31/71 (43.7%) 11/71 (15.5%) 4/71 (5.6%) 1/71 (1.4%) n = 71

8/48 (16.7%) 15/48 (31.3%) 13/48 (27.1%) 9/48 (18.8%) 3/48 (6.3%) n = 48

48/198 (24.2%) 77/198 (38.9%) 42/198 (21.2%) 22/198 (11.1%) 9/198 (4.6%) n = 198

Note: Three first-year fellows did not answer the question.

552

www.pec-online.com

© 2014 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Pediatric Emergency Care • Volume 31, Number 8, August 2015

TABLE 3. Timing of Debriefing Sessions in the ED Timing

Responses

Immediately Within 6 h 6–24 h later 1–6 d later ≥1 wk later Not applicable Total

77/199 (38.7%) 74/199 (37.2%) 18/199 (9.0%) 21/199 (10.6%) 13/199 (6.5%) 50/199 (25.1%) n = 199

Note: Fellows could select more than 1 response for this question. Two fellows did not answer the question.

Other impediments to debriefing include lack of qualified leaders, discomfort surrounding the critical event, and fear of criticism or judgment from colleagues.25 Despite these obstacles, Mullan et al24 described the successful creation and implementation of a standardized debriefing tool known as Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) in a large pediatric ED. With simple instruction by a self-guided form, a multidisciplinary team implemented the tool in 63 of 241 events involving cardiopulmonary resuscitation, intubation, and/or defibrillation over a 1-year period. The median start time to debriefing was 33 minutes after the resuscitation, and the median duration was 10 minutes. Our study participants reported the majority of debriefing sessions to have occurred either immediately or within 6 hours of the resuscitation, which is consistent with the timing of debriefing events reported by Mullan et al.24 This may represent the practicality of holding a debriefing session within the same shift for a varied group of medical providers. A recent survey of Canadian PEM physicians, nurses, and fellows demonstrated that the majority of debriefings do not

Debriefing After Medical Resuscitations

follow a structured format.25 This is similar to our results, where 86.5% of fellows in our study reported no standardized approach to the debriefings in which they participated. Similarly, Sandhu et al25 noted a wide variety in the topics addressed during the postresuscitation debriefing sessions, including issues related to teamwork, leadership, communication, resource allocation, medical management, and emotional release. While the content of debriefing sessions may vary depending on the preceding resuscitation, it may benefit medical providers to receive training on debriefing tools and techniques to enhance the overall debriefing experience. Most PEM fellows in our study reported never having received formal training on how to effectively lead a debriefing session. Because the majority of the debriefing sessions in the ED are led by PEM attending physicians, fellows usually learn to debrief by role modeling during the infrequent instances when debriefing occurs. This form of learning may not be available for the 30.5% of PEM fellows who reported never having participated in a debriefing session. In addition, few studies report the use of formal or validated educational tools to help guide debriefing.6,12,24,26 Whereas some fellows are able to learn debriefing skills by emulating their attending physicians, we found that 48.7% of PEM fellows indicated their comfort level with leading a debriefing session as neutral to very uncomfortable, indicating room for improvement. The lack of any apparent increase in debriefing frequency with increasing resuscitation frequency may suggest that resuscitation experience alone is not the solution to increasing the frequency of debriefing. A structured program that offers education on debriefing techniques, as well as simulation opportunities to practice facilitating debriefing sessions, could provide a standard foundation for learning this important skill.27,28 Given evidence- and consensus-based recommendations for debriefing and the level of fellows’ interest in the topic, fellowship programs should consider incorporating formal debriefing education into the existing PEM curriculum.

FIGURE 1. Fellows’ level of comfort leading debriefing sessions by year of fellowship training. Note: One first-year fellow and 1 second-year fellow did not answer the question. © 2014 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

www.pec-online.com

553

Pediatric Emergency Care • Volume 31, Number 8, August 2015

Zinns et al

Limitations There are several limitations to this cross-sectional study. First, we experienced a 48.6% nonresponse rate. Fellows who completed the survey may have differed in their experiences, perceptions, and attitudes from those who did not participate, potentially contributing to a nonresponse bias. Second, our survey did not undergo a formal validation process. We piloted the survey with the critical care fellows at our institution before disseminating the survey to PEM fellows at other programs. Differences in work experience, environment, and culture exist between critical care and emergency medicine that may have influenced perceptions of the survey questions. Third, cumulative data were collected anonymously. Our surveys were purposefully conducted midyear, approximately 6 to 9 months after first-year fellows began their fellowship training to allow them to gain sufficient experience upon which to comment. While first-year fellows’ outside commitments may preclude them from being involved in ED resuscitations and debriefings, our results indicate that 57.3% of first-year fellows had participated in at least 6 resuscitations since starting fellowship, and 9.8% had participated in more than 20 resuscitations. Fourth, this study is subject to recall bias as fellows were asked to reflect on their experiences in the ED throughout their training. It is possible that fellows were unable to remember all of the details regarding medical resuscitations and debriefings, thus affecting the accuracy of our data. Finally, this study was limited to US ACGME-accredited PEM fellows. According to ABP21 and ACGME29 online reports, the enrolled number of trainees in PEM fellowships continues to expand each year, leading to more fellows early in training, which may have contributed to the skewed response rate reported in our study. In addition, our fellows’ experiences and attitudes may not be applicable to trainees in non-US, non–ACGME-accredited programs.

CONCLUSIONS Our study found that although PEM fellows report frequent involvement in medical resuscitations in the ED, they seldom participate in or lead debriefing sessions afterward. Pediatric emergency medicine fellows currently receive little formal training on postresuscitation debriefing and are typically not comfortable leading debriefing sessions. Notably, they are interested in learning more about debriefing. The availability of a structured training program could offer PEM fellows the opportunity to develop the skills and confidence to successfully facilitate future debriefing sessions after medical resuscitations in the pediatric ED. ACKNOWLEDGMENT The authors thank Jennifer Faerber, senior biostatistician, The Children’s Hospital of Philadelphia, Philadelphia, PA.

7. Fanning RM, Gana DM. The role of debriefing in simulation-based learning. Simulation Healthc. 2007;2:115–125. 8. Magyar J, Theophilos T. Review article: debriefing critical incidents in the emergency department. Emerg Med Australas. 2010;22:499–506. 9. Pittman J, Turner B, Gabbott DA. Communication between members of the cardiac arrest team—a postal survey. Resuscitation. 2001;49:175–177. 10. 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. 11. Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med. 2008;168:1063–1069. 12. Theophilos T, Magyar J, Babl FE. Debriefing critical incidents in the pediatric emergency department: current practice and perceived needs in Australia and New Zealand. Emerg Med Australas. 2009;21:479–483. 13. Keene EA, Hutton N, Hall B, et al. Bereavement debriefing sessions: an intervention to support health care professionals in management their grief after the death of a patient. Pediatr Nurs. 2010;36:185–189. 14. Yang CP, Leung J, Hunt EA, et al. Pediatric residents do not feel prepared for the most unsettling situations they face in the pediatric intensive care unit. J Palliat Care Med. 2011;14:25–30. 15. Brett-Fleegler M, Rudolph J, Eppich W, et al. Debriefing assessment for simulation in healthcare. Simulation Healthc. 2012;7:288–294. 16. Maloney C. Critical incident stress debriefing and pediatric nurses: an approach to support the work environment and mitigate negative consequences. Pediatr Nurs. 2012;38:110–113. 17. Salas E, Klein C, King H, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt Comm J Qual Patient Saf. 2008; 34:518–527. 18. Bhanji F, Mancini ME, Sinz E, et al. Part 16: education, implementation, and teams: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S920–S933. 19. Committee on Pediatric Emergency Medicine, American Academy of Pediatrics, Krug SE, Frush K. Patient safety in the pediatric emergency care setting. Pediatrics. 2007;120:1367–1375. 20. Nolan JP, Soar J, Zideman DA, et al. European resuscitation council guidelines for resuscitation 2010: section 1. Executive summary. Resuscitation. 2010;81:1219–1276. 21. The American Board of Pediatrics 2012 Workforce Data. The American Board of Pediatric Web site. Available at: https://www.abp.org/abpwebsite/ stats/wrkfrc/workforcebook.pdf. Accessed February 2014. 22. Ireland S, Gilchrist J, Maconochie I. Debriefing after failed paediatric resuscitation: a survey of current UK practice. Emerg Med J. 2008;6:328–330. 23. Serwint JR. One method of coping: resident debriefing after the death of a patient. J Pediatr. 2004;145:229–234.

REFERENCES

24. Mullan PC, Wuestner E, Kerr TD, et al. Implementation of an in situ qualitative debriefing tool for resuscitations. Resuscitation. 2012;12:1–17.

1. Ahrens WR, Hart RG. Emergency physicians’ experience with pediatric death. Am J Emerg Med. 1997;15:642–643.

25. Sandhu N, Eppich W, Mikrogianakis A, et al. Postresuscitation debriefing in the pediatric emergency department: a national needs assessment. Can J Emerg Med. 2013;15:1–10.

2. Hart RG, Ahrens WR. Coping with pediatric death in the ED by learning from parental experience. Am J Emerg Med. 1998;16:67–68. 3. Strote J, Schroeder E, Lemos J, et al. Academic emergency physicians’ experiences with patient death. Acad Emerg Med. 2011;18:255–260. 4. Advanced cardiovascular life support: section 7: algorithm approach to ACLS emergencies. Circulation. 2000:I-136-I-139. 5. 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. 6. Couper K, Perkins GD. Debriefing after resuscitation. Curr Opin. 2013;19:1–7.

554

www.pec-online.com

26. Raemer D, Anderson M, Cheng A, et al. Research regarding debriefing as part of the learning process. Simulation Healthc. 2011;6:S52–S57. 27. Aronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach. 2010:1–6. 28. Zebuhr C, Sutton RM, Morrison W, et al. Evaluation of quantitative debriefing after pediatric cardiac arrest. Resuscitation. 2012;83: 1124–1128. 29. Accreditation Council for Graduate Medical Education. http://www.acgme.org. Accessed February 2014.

© 2014 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

National Survey of Pediatric Emergency Medicine Fellows on Debriefing After Medical Resuscitations.

Medical resuscitations of critically ill children in the emergency department are stressful events requiring a coordinated team effort. Current guidel...
232KB Sizes 1 Downloads 8 Views