Critical event debriefing: a checklist for the aftermath.

PURPOSE OF REVIEW: Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal critical event debriefing. RECENT FINDINGS: Evidence-based key processes to consider for proximal critical event debriefing can be summarized by the WATER mnemonic: Welfare check (assessing team members' emotional and physical wellbeing to continue providing care); Acute/short-term corrections (matters to be addressed before the next case); Team reactions and reflections (summarizing case; listening to team member reactions; plus/delta conversation); Education (lessons learned from the event and debriefing); Resource awareness and longer term needs [follow-up (e.g. safety/quality improvement report), local peer-support and employee assistance resources]. A cognitive aid to accompany this mnemonic is provided with the publication. SUMMARY: There is growing literature on how to conduct proximal perioperative critical event debriefing. Evidence-based best practices, as well as a cognitive aid to apply them, may help bridge the gap between theory and clinical practice. In this era of increased attention to burnout and wellness, the consideration of interventions to improve the quality and frequency of critical event debriefing is paramount.

Bolstering clinician resilience through an interprofessional, web-based nightly debriefing program for emergency departments during the COVID-19 pandemic.

The COVID-19 pandemic has instigated significant changes for health care systems. With clinician burnout rising, efforts to promote clinician resilience are essential. Within this quality improvement project, an interprofessional debriefing program (Brigham Resilience in COVID-19-pandemic Emergency Forum-BRIEF) was developed within two emergency departments (EDs). An interprofessional group of ED providers led optional, nightly debriefings using a web-based portal to connect with ED clinicians for six weeks. In total, 81 interprofessional staff participated in nightly debriefings with a 47% attendance rate. On average, three participants attended the BRIEF nightly (range = 2-8) to discuss the challenges of social distancing, scarce resources, high acuity, clinician burnout and mental health. Participation increased as rates of COVID-19 positive patients rose. Debriefing leaders provided ED leadership with summaries of clinician experiences and suggestions for improvements. Feedback supported quality improvement initiatives within the ED and greater mental health support for staff. Clinicians and administrators provided positive feedback regarding the program's impact on clinician morale, and clinical processes that promoted the safety and quality of patient care. Optional debriefing with receptive departmental leadership may be a successful tool to support clinicians and hospitals during critical events.

Neonatal resuscitation experience curves: simulation based mastery learning booster sessions and skill decay patterns among pediatric residents.

Background Following neonatal resuscitation program (NRP) training, decay in clinical skills can occur. Simulation-based deliberate practice (SBDP) has been shown to maintain NRP skills to a variable extent. Our study objectives were (a) to determine whether a single 30 min simulation-based intervention that incorporates SBDP and mastery learning (ML) can effectively restore skills and prevent skill decay and (b) to compare different timing options. Methods Following NRP certification, pediatric residents were randomly assigned to receive a video-recorded baseline assessment plus SBDP-ML refresher education at between 6 and 9 months (early) or between 9 and 12 months (late). One year following initial certification, participants had repeat skill retention videotaped evaluations. Participants were scored by blinded NRP instructors using validated criteria scoring tools and assigned a global performance rating score (GRS). Results Twenty-seven participants were included. Residents in both early and late groups showed significant skill decay 7 and 10 months after initial NRP. SBDP-ML booster sessions significantly improved participants' immediate NRP performance scores (p<0.001), which persisted for 2 months, but were again lower 4 months later. Conclusions NRP skills may be boosted to mastery levels after a short SBDP-ML intervention and do not appear to significantly decline after 2 months. Brief booster training could potentially serve as a useful supplement to traditional NRP training for pediatric residents.

A collaborative clinical simulation model for the development of competencies by medical students.

Herein, we present a new collaborative clinical simulation (CCS) model for the development of medical competencies by medical students. The model is a comprehensive compendium of published considerations and recommendations on clinical simulation (CS) and computer-supported collaborative learning (CSCL). Currently, there are no educational models combining CS and CSCL. The CCS model was designed for the acquisition and assessment of clinical competencies; working collaboratively and supported by technology, small groups of medical students independently design and perform simulated cases. The model includes four phases in which the learning objectives, short case scenarios, materials, indices, and the clinical simulation are designed, monitored, rated and debriefed.

Bedside ultrasound curriculum for medical students: report of a blended learning curriculum implementation and validation.

BACKGROUND: Medical students on clinical rotations rarely receive formal bedside ultrasound (BUS) training. We designed, implemented, and evaluated a standardized BUS curriculum for medical students on their Emergency Medicine (EM) rotation. Teaching was aimed toward influencing four cognitive and psychomotor learning domains: BUS instrumentation knowledge, image interpretation, image acquisition, and procedural guidance. METHODS: Participants viewed three instructional Web-based tutorials on BUS instrumentation, the Focused Assessment for Sonography in Trauma (FAST) examination and ultrasound-guided central venous catheter (CVC) placement. Subsequently, participants attended a 3-hour hands-on training session to discuss the same content area and practice with faculty coaches. A Web-based, multiple-choice questionnaire was administered before and after the session. During the final week of the rotation, students returned for skills assessments on FAST image acquisition and CVC placement. RESULTS: Forty-five medical students on an EM rotation were enrolled. Sonographic knowledge overall mean score improved significantly from 66.6% (SD ±11.2) to 85.7% (SD ±10.0), corresponding to a mean difference of 19.1% (95% CI 15.5-22.7; p < 0.001). There were high pass rates for FAST (89.0%, 40/45) and CVC (96.0%, 43/45) skills assessments. There was no significant difference between medical student posttest and EM resident test scores 85.7% (SD ±10.0) and 88.1% (SD ± 7.6) (p = 0.40), respectively. CONCLUSIONS: A formal BUS curriculum for medical students on EM rotation positively influenced performance in several key learning domains. As BUS competency is required for residency in EM and other specialties, medical schools could consider routinely incorporating BUS teaching into their clinical rotation curricula.

E-Learning with virtual teammates: A novel approach to interprofessional education.

The Institute of Medicine identified interprofessional education (IPE) as a key innovation for achieving the triple aim of better care, better outcomes, and reduced healthcare costs. Yet, a shortage of qualified faculty and difficulty with aligning learners' schedules often prevent sustainable and scalable IPE. A virtual IPE intervention was developed to circumvent these barriers and compared to a blended-learning IPE intervention. We used a pre-test and post-test design with two comparison interventions to test the effects of these IPE interventions on changes in teamwork knowledge, skills, and attitudes. The interventions were delivered to pre-licensure learners at a large, metropolitan medical and a nursing school. We used one-sample and independent-sample t-tests to analyze data from 220 learners who received the blended-learning intervention in 2011 and 540 learners who received the virtual learning intervention in 2012. The students in the blended-learning intervention did not significantly (p < 0.05) outperform the students in the virtual learning intervention for any of the measured outcomes, except for medical students' attitudes around team value. Virtual IPE learning is an effective, scalable, and sustainable solution for imparting foundational teamwork knowledge in health profession students.

What's your best time? Chronometry in the learning of medical procedures.

OBJECTIVES: Most medical procedures have a time element. It is uncommon, however, to explicitly use chronometry, the measurement of time, in the learning of these procedures. This study considered whether instructional designs that include chronometry could improve deliberate practice and be used in meaningful formative assessments. METHODS: A selective review of the medical education literature was undertaken to identify how chronometry was used in a broad sampling of medical education research in the learning of medical procedures. We identified prior publications in which time measurement was used either directly as a pedagogic intervention or as an assessment method in a medical school programme. RESULTS: Our review suggests a number of desirable features of chronometry. For the individual learner, procedural time measurements can demonstrate both improving ability and increasing consistency. Chronometry can enhance instructional designs involving deliberate practice by facilitating overlearning (i.e. learning that goes beyond minimum competence), increasing the challenge level and enhancing self-regulation of learning (e.g. self-competition). Breaking down chronometric data into meaningful interval or split times might further inform instructional designs. CONCLUSIONS: Chronometry has the potential to contribute to instructional designs and assessment methods in medical procedures training. However, more research is needed to elucidate its full potential and describe possible negative consequences of this widely available but underutilised educational tool.

I like what you are saying, but only if i feel safe: Psychological safety moderates the relationship between voice and perceived contribution to healthcare team effectiveness.

Introduction: Are nurses who voice work-related concerns viewed as positive contributors to a team? We propose that the extent to which healthcare professionals consider voice by nurses as helpful for the team depends on how psychologically safe they feel. Specifically, we hypothesized that psychological safety moderates the relationship between voice of a lower ranking team member (i.e., a nurse) and perceived contribution by others, such that voice is more likely to be seen as valuable for team decision-making when psychological safety is high but not when it is low. Methods: We tested our hypotheses with a randomized between-subjects experiment using a sample of emergency medicine nurses and physicians. Participants evaluated a nurse who either did or did not speak up with alternative suggestions during emergency patient treatment. Results: Results confirmed our hypotheses: At higher levels of psychological safety the nurse's voice was considered as more helpful than withholding of voice for team decision-making. This was not the case at lower levels of psychological safety. This effect was stable when including important control variables (i.e., hierarchical position, work experience, gender). Discussion: Our results shed light on how evaluations of voice are contingent on perceptions of a psychologically safe team context.

Teaching, coaching, or debriefing With Good Judgment: a roadmap for implementing "With Good Judgment" across the SimZones.

Simulation-based learning occurs in multiple contexts, and one teaching style cannot adequately cover the needs at each learning level. For example, reflective debriefing, often used following a complex simulation case, is not what is needed when learning new skills. When to use which facilitation style is a question that educators often overlook or struggle to determine. SimZones is a framework used to clarify the multiple contexts in simulation. This framework, combined with elements of Debriefing With Good Judgment, can help educators match the appropriate facilitation style with learner needs and learning context. We have distilled the core elements of the "with good judgment" approach to debriefing and applied them to the SimZones framework to guide educators with (1) what type of learning can be expected with each learning context, (2) what behaviors and activities can be expected of the learners in each learning context, (3) what instructional strategies are most effectively used at each stage, and (4) what are the implications for the teacher-learner relationship.

Accreditation of Simulation Fellowships and Training Programs: More Checkboxes or Elevating the Field?

SUMMARY STATEMENT: As the field of healthcare simulation matures, formal accreditation for simulation fellowships and training programs has become increasingly available and touted as a solution to standardize the education of those specializing in healthcare simulation. Some simulation experts hold opposing views regarding the potential value of simulation fellowship program accreditation. We report on the proceedings of a spirited debate at the 20th International Meeting on Simulation in Healthcare in January 2020. Pro arguments view accreditation as the logical evolution of a maturing profession: improving training quality through standard setting, providing external validation for individual programs, and enhancing the program's return on investment. Con arguments view accreditation as an incompletely formulated construct; burdensome to the "financially strapped" fellowship director, misaligned with simulation fellows' needs and expectations, and confusing to administrators mistakenly equating accreditation with credentialing. In addition, opponents of accreditation postulate that incorporating curricular standards, practice guidelines, and strategies derived and implemented without rigor, supporting evidence and universal consensus is premature. This narrative review of our debate compares and contrasts contemporary perspectives on simulation fellowship program accreditation, concluding with formal recommendations for learners, administrators, sponsors, and accrediting bodies.

Clinical debriefing during the COVID-19 pandemic: hurdles and opportunities for healthcare teams.

The COVID-19 pandemic and the subsequent pressures on healthcare staff and resources have exacerbated the need for clinical teams to reflect and learn from workplace experiences. Surges in critically ill patients, the impact of the disease on the workforce and long term adjustments in work and life have upturned our normality. Whilst this situation has generated a new 'connectedness' within healthcare workers, it also continues to test our resilience.An international multi-professional collaboration has guided the identification of ongoing difficulties to effective communication and debriefing, as well as emerging opportunities to promote a culture of dialogue. This article outlines pandemic related barriers and new possibilities categorising them according to task management, teamwork, situational awareness and decision making. It describes their direct and indirect impact on clinical debriefing and signposts towards solutions to overcome challenges and, building on new bridges, advance team conversations that allow us to learn, improve and support each other.This pandemic has brought clinical professionals together; nevertheless, it is essential to invest in further developing and supporting cohesive teams. Debriefing enables healthcare teams and educators to mitigate stress, build resilience and promote a culture of continuous learning and patient care improvement.

Self-directed video versus instructor-based neonatal resuscitation training: a randomized controlled blinded non-inferiority multicenter international study.

OBJECTIVE: To compare the efficacy of video-assisted self-directed neonatal resuscitation skills course with video-assisted facilitator-led course. METHODS: This multicenter, randomized, blinded, non-inferiority-controlled trial compared two methods of teaching basic neonatal resuscitation skills using mask ventilation. Groups of novice providers watched an instructional video. One group received instructor facilitation (Ins-Video). The other group did not (Self-Video). An Objective Structured Clinical Exam (OSCE) measured skills performance, and a written test gauged knowledge. RESULTS: One hundred and thirty-four students completed the study. Sixty-three of 68 in the Self-Video Group (92.6%) and 59 of 66 in the Ins-Video Group (89.4%) achieved post-training competency in positive pressure ventilation (primary outcome). OSCE passing rates were low in both groups. Knowledge survey scores were comparable between groups and non-inferior. CONCLUSIONS: Video self-instruction taught novice providers positive pressure ventilation skills and theoretical knowledge, but it was insufficient for mastery of basic neonatal resuscitation in simulation environment.

The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain.

OBJECTIVES: We sought to determine whether risk tolerance as measured by scales (malpractice fear scale [MFS], risk-taking scale [RTS], and stress from uncertainty scale [SUS]) is associated with decisions to admit or use computed tomography (CT) coronary angiogram and decisions to order cardiac markers in emergency department (ED) patients with chest pain. We also studied if the opening of an ED-based observation unit affected the relationship between risk scales and admission decisions. METHODS: Data from a prospective study of ED patients 30 years or older with chest pain were used. Risk scales were administered to ED attending physicians who initially evaluated them. Physicians were divided into quartiles for each separate risk scale. Fisher's exact test and logistic regression were used for statistical analysis. RESULTS: A total of 2872 patients were evaluated by 31 physicians. The most risk-averse quartile of RTS was associated with higher admission rates (78% vs 68%) and greater use of cardiac markers (83% vs 78%) vs the least risk-averse quartile. This was not true for MFS or SUS. Similar associations were observed in low-risk patients (Thrombolysis in Myocardial Infarction risk score of 0 or 1). The observation unit was not associated with a higher admission rate and did not modify the relationship between risk scales and admission rates. CONCLUSION: The RTS was associated with the decision to admit or use computed tomography coronary angiogram, as well as the use of cardiac markers, whereas the MFS and SUS were not. The observation unit did not affect admission rates and nor did it affect how physician's risk tolerance affects admission decisions.

Diarrhea in the Returning Traveler: A Simulation Case for Medical Students to Learn About Global Health.

Introduction: As global travel becomes more prevalent, medical students may be asked to care for patients with unforeseen exposures. We developed a simulation where clerkship medical students interviewed and examined a patient with recent travel who presented with bloody diarrhea and abdominal pain and was diagnosed with amebic colitis. The students had the opportunity to develop a differential diagnosis and discuss the workup of the patient. Methods: We divided students into two groups. Each group took a turn participating in the simulation while the other group observed. Students were expected to interview and examine the patient as well as treat any urgent findings and develop a differential diagnosis. After each simulation, we reconvened with both groups for a faculty-led debriefing session to discuss the learning objectives, including approaches to caring for a patient with diarrhea and the differential diagnosis and workup of bloody diarrhea. Results: To date, five different groups of six to 12 students have completed this simulation. The module has been well received, and 100% of survey respondents have agreed that after completing the activity, they had a better understanding of how to approach a recent traveler with diarrhea and abdominal pain. Discussion: While most medical students will not travel abroad for traditional global health experiences, many will encounter patients with recent travel or immigration and must therefore be prepared to treat diseases typically categorized as global health. We developed this simulation and successfully incorporated workup of a returning traveler into the medical school curriculum for clerkship students.

Real-Time Debriefing After Critical Events: Exploring the Gap Between Principle and Reality.

Debriefing after perioperative crises (eg, cardiac arrest, massive hemorrhage) is a well-described practice that can provide benefits to individuals, teams, and health systems. Debriefing has also been embraced by high-stakes industries outside of health care. Yet, in studies of actual clinical practice, there are many critical events that do not get debriefed. This article explores the gap that exists between principle and reality and the factors and strategies to offer opportunities to reflect on actual critical events, when indicated, across the increasing scope of environments where anesthesia care is provided.

Development and implementation of an end-of-shift clinical debriefing method for emergency departments during COVID-19.

BACKGROUND: Multiple guidelines recommend debriefing after clinical events in the emergency department (ED) to improve performance, but their implementation has been limited. We aimed to start a clinical debriefing program to identify opportunities to address teamwork and patient safety during the COVID-19 pandemic. METHODS: We reviewed existing literature on best-practice guidelines to answer key clinical debriefing program design questions. An end-of-shift huddle format for the debriefs allowed multiple cases of suspected or confirmed COVID-19 illness to be discussed in the same session, promoting situational awareness and team learning. A novel ED-based clinical debriefing tool was implemented and titled Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE). A facilitator experienced in simulation debriefings would facilitate a short (10-25 min) discussion of the relevant cases by following a scripted series of stages for debriefing. Data on the number of debriefing opportunities, frequency of utilization of debriefing, debriefing location, and professional background of the facilitator were analyzed. RESULTS: During the study period, the ED treated 3386 suspected or confirmed COVID-19 cases, with 11 deaths and 77 ICU admissions. Of the 187 debriefing opportunities in the first 8-week period, 163 (87.2%) were performed. Of the 24 debriefings not performed, 21 (87.5%) of these were during the four first weeks (21/24; 87.5%). Clinical debriefings had a median duration of 10 min (IQR 7-13). They were mostly facilitated by a nurse (85.9%) and mainly performed remotely (89.8%). CONCLUSION: Debriefing with DISCOVER-PHASE during the COVID-19 pandemic were performed often, were relatively brief, and were most often led remotely by a nurse facilitator. Future research should describe the clinical and organizational impact of this DISCOVER-PHASE.

COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought.

BACKGROUND: The world is facing a massive burden from the coronavirus disease 2019 (COVID-19) pandemic. Governments took the extraordinary step of locking down their own countries to curb the spread of the coronavirus. After weeks of severe restrictions, countries have begun to relax their strict lockdown measures. However, reopening will not be back to normal.Simulation facilities (SF) are training spaces that enable health professionals and students to learn skills and procedures in a safe and protected environment. Today's clinicians and students have an expectation that simulation laboratories are part of lifelong healthcare education. There is great uncertainty about how COVID-19 will impact future training in SF. In particular, the delivery of training activities will benefit of adequate safety measures implemented for all individuals involved.This paper discusses how to safely reopen SF in the post-lockdown phase. MAIN BODY: The paper outlines 10 focus points and provides operational tips and recommendations consistent with current international guidelines to reopen SF safely in the post-lockdown phase. Considering a variety of national advices and regulations which describe initial measures for the reopening of workplaces as well as international public health recommendations, we provide points of reflection that can guide decision-makers and SF leaders on how to develop local approaches to specific challenges. The tips have been laid out taking also into account two main factors: (a) the SF audience, mainly consisting of undergraduate and postgraduate healthcare professionals, who might face exposure to COVID-19 infection, and (b) for many simulation-based activities, such as teamwork training, adequate physical distancing cannot be maintained. CONCLUSIONS: The planning of future activities will have to be based not only on safety but also on flexibility principles.Sharing common methods consistent with national and international health guidelines, while taking into account the specific characteristics of the different contexts and centres, will ultimately foster dissemination of good practices.This article seeks to further the conversation. It is our hope that this manuscript will prompt research about the impact of such mitigation procedures and measures in different countries.