Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

BACKGROUND: Debriefing is increasingly used in clinical environments. Surveys indicate staff support for debriefing clinical events, but little is known about the specific effects of debriefing on healthcare workers in the workplace. INFO (Immediate, Not for personal assessment, Fast facilitated feedback, and Opportunity to support and ask questions) is a charge nurse facilitated clinical event debriefing program implemented in 2016 and currently used in five Emergency Departments (ED) in Calgary, Alberta, Canada. There have been more than 840 documented INFO debriefings. METHODS: Thirty interprofessional ED healthcare workers were recruited through posters and email to take part in voluntary one-on-one interviews using a standardized question script that asked participants about their experience with INFO debriefing assessments. Specifically, participants were asked to provide demographic information, give feedback about their involvement in INFO clinical debriefings, impact of debriefings on their clinical practice, stress levels and wellbeing. Interviews were transcribed and analysed using NVivo software. RESULTS: Forty-five healthcare workers replied to the initial recruitment methods with fifteen not responding to follow-up communication. Overall, staff satisfaction with INFO debriefing was highly rated. A qualitative thematic analysis to saturation approach was used to analyse the data. Five main themes were identified: 1.Effect of debriefing on clinical practice and patient care. 2. Psychological safety and teamwork. 3. Emotional acknowledgment after critical events. 4. Managing work stress in the ED. 5. Barriers to debriefing. CONCLUSIONS: In this study, debriefing in the ED helped interprofessional healthcare workers manage stress, provide improved patient care and teamwork while acknowledging emotions. This study specifically involved INFO, however, there are similarities that make our findings applicable to other clinical event debriefing programs. We believe this study provides further evidence supporting debriefing in clinical care areas.

RéSUMé: CONTEXTE: Le débriefing est de plus en plus utilisé dans les environnements cliniques. Les enquêtes indiquent que le personnel est favorable au débriefing des événements cliniques, mais on sait peu de choses sur les effets spécifiques du débriefing sur les travailleurs de la santé sur le lieu de travail. INFO (Immediate, Not for personal assessment, Fast facilitated feedback, and Opportunity to support and ask questions) est un programme de débriefing d'événements cliniques animé par l'infirmière en chef, mis en œuvre en 2016 et actuellement utilisé dans cinq services d'urgence (SU) à Calgary, Alberta, Canada. Il y a eu plus de 840 débriefings INFO documentés. MéTHODES: Trente travailleurs interprofessionnels des services d'urgence ont été recrutés par le biais d'affiches et de courriels pour participer à des entretiens individuels volontaires à l'aide d'un script de questions standardisé qui demandait aux participants de parler de leur expérience des évaluations de débriefing INFO. Plus précisément, les participants ont été invités à fournir des informations démographiques, à donner leur avis sur leur participation aux débriefings cliniques INFO, sur l'impact des débriefings sur leur pratique clinique, sur leur niveau de stress et sur leur bien-être. Les entretiens ont été transcrits et analysés à l'aide du logiciel NVivo. RéSULTATS: Quarante-cinq travailleurs de la santé ont répondu aux méthodes de recrutement initiales, quinze n'ont pas répondu à la communication de suivi. Dans l'ensemble, la satisfaction du personnel à l'égard du compte rendu d'INFO a été très bonne. Une analyse thématique qualitative jusqu'à saturation a été utilisée pour analyser les données. Cinq thèmes principaux ont été identifiés : 1. l'effet du débriefing sur la pratique clinique et les soins aux patients. 2. La sécurité psychologique et le travail en équipe. 3. Reconnaissance émotionnelle après des événements critiques. 4. Gestion du stress au travail dans les services d'urgence. 5. Obstacles au débriefing. CONCLUSIONS: Dans cette étude, le débriefing aux urgences a aidé les travailleurs de la santé interprofessionnels à gérer le stress, à améliorer les soins aux patients et le travail d'équipe tout en reconnaissant les émotions. Cette étude a porté spécifiquement sur INFO, mais il existe des similitudes qui rendent nos résultats applicables à d'autres programmes de débriefing d'événements cliniques. Nous pensons que cette étude apporte des preuves supplémentaires en faveur du débriefing dans les domaines des soins cliniques.

Charge nurse facilitated clinical debriefing in the emergency department.

ABSTRACTThis paper describes the development and implementation of the INFO (immediate, not for personal assessment, fast facilitated feedback, and opportunity to ask questions) clinical debriefing process. INFO enabled charge nurses to facilitate a group debriefing after critical events across three adult emergency departments (EDs) in Calgary, Alberta. Prior to implementation at our institutions, ED critical event debriefing was a highly variable event. Post-implementation, INFO critical event debriefings have become part of our ED culture, take place regularly in our EDs (254 documented debriefings between March 2016 and September 2017), with recommendations arising from these debriefings being introduced into clinical practice. The INFO clinical debriefing process addresses two significant barriers to regular ED clinical debriefing: a lack of trained facilitators and the focus on physician-led debriefings. Our experience shows that a nurse-facilitated debriefing is feasible, can be successfully implemented in diverse EDs, and can be performed by relatively inexperienced debriefers. A structured approach means that debriefings are more likely to take place and become a routine part of improving team management of high stakes or unexpected clinical events.

Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter.

OBJECTIVES: Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice. METHODS: This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes. RESULTS: In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone. CONCLUSION: There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

The Q-Cycle Mechanism of the bc1 Complex: A Biologist's Perspective on Atomistic Studies.

The Q-cycle mechanism of the bc1 complex is now well enough understood to allow application of advanced computational approaches to the study of atomistic processes. In addition to the main features of the mechanism, these include control and gating of the bifurcated reaction at the Qo-site, through which generation of damaging reactive oxygen species is minimized. We report a new molecular dynamics model of the Rhodobacter sphaeroides bc1 complex implemented in a native membrane, and constructed so as to eliminate blemishes apparent in earlier Rhodobacter models. Unconstrained MD simulations after equilibration with ubiquinol and ubiquinone respectively at Qo- and Qi-sites show that substrate binding configurations at both sites are different in important details from earlier models. We also demonstrate a new Qo-site intermediate, formed in the sub-ms time range, in which semiquinone remains complexed with the reduced iron sulfur protein. We discuss this, and a spring-loaded mechanism for modulating interactions of the iron sulfur protein with occupants of the Qo-site, in the context of control and gating roles. Such atomistic features of the mechanism can usefully be explored through simulation, but we stress the importance of constraints from physical chemistry and biology, both in setting up a simulation and in interpreting results.

Effectiveness of educational intervention on the congruence of prostate and rectal contouring as compared with a gold standard in three-dimensional radiotherapy for prostate.

PURPOSE: To examine effects of a teaching intervention on precise delineation of the prostate and rectum during planning of three-dimensional conformal radiotherapy (3D-CRT) for prostate cancer. METHODS AND MATERIALS: A pretest, posttest, randomized controlled group design was used. During pretest all participants contoured prostate and rectum on planning CT. Afterward, they participated in two types of workshops. The experimental group engaged in an interactive teaching session focused on prostate and rectum MR anatomy compared with CT anatomy. The control group focused on 3D-CRT planning without mention of prostate or rectal contouring. The experimental group practiced on fused MR-CT images, whereas the control group practiced on CT images. All participants completed the posttest. RESULTS: Thirty-one trainees (12 male, 19 female) were randomly assigned to two groups, 17 in the experimental arm, and 14 in the control group. Seventeen felt familiar or very familiar with pelvic organ contouring, 12 somewhat, and 2 had never done it. Thirteen felt confident with organ contouring, 13 somewhat, and 5 not confident. The demographics and composition of groups were analyzed with chi(2) and repeated-measures analysis of variance with the two groups (experimental or control) and two tests (pre- or posttest) as factors. Satisfaction with the course and long-term effects of the course on practice were assessed with immediate and delayed surveys. All performance variables showed a similar pattern of results. CONCLUSIONS: The training sessions improved the technical performance similarly in both groups. Participants were satisfied with the course content, and the delayed survey reflected that cognitively participants felt more confident with prostate and rectum contouring and would investigate opportunities to learn more about organ contouring.

D1-arginine257 mutants (R257E, K, and Q) of Chlamydomonas reinhardtii have a lowered QB redox potential: analysis of thermoluminescence and fluorescence measurements.

Arginine257 (R257), in the de-helix that caps the Q(B) site of the D1 protein, has been shown by mutational studies to play a key role in the sensitivity of Photosystem II (PS II) to bicarbonate-reversible binding of the formate anion. In this article, the role of this residue has been further investigated through D1 mutations (R257E, R257Q, and R257K) in Chlamydomonas reinhardtii. We have investigated the activity of the Q(B) site by studying differences from wild type on the steady-state turnover of PS II, as assayed through chlorophyll (Chl) a fluorescence yield decay after flash excitation. The effects of p-benzoquinone (BQ, which oxidizes reduced Q(B), Q(B)(-) ) and 3-(3,4-dichlorophenyl)-1,1-dimethylurea (DCMU, which blocks electron flow from Q(A)(-) to Q(B)) were measured. The equilibrium constants of the two-electron gate were obtained through thermoluminescence measurements. The thermoluminescence properties were changed in the mutants, especially when observed after pretreatment with 100 microM BQ. A theoretical analysis of the thermoluminescence data, based mainly on the recombination pathways model of Rappaport et al. (2005), led to the conclusion that the free-energy difference for the recombination of Q(B)(-) with S(2) was reduced by 20-40 mV in the three mutants (D1-R257K, D1-R257Q, and D1-R257E); this was interpreted to be due to a lowering of the redox potential of Q(B)/Q(B)(-). Further, since the recombination of Q(A)(-) with S(2) was unaffected, we suggest that no significant change in redox potential of Q(A)/Q(A)(-) occurred in these three mutants. The maximum variable Chl a fluorescence yield is lowered in the mutants, in the order R257K > R257Q > R257E, compared to wild type. Our analysis of the binary oscillations in Chl a fluorescence following pretreatment of cells with BQ showed that turnover of the Q(B) site was relatively unaffected in the three mutants. The mutant D1-R257E had the lowest growth rate and steady-state activity and showed the weakest binary oscillations. We conclude that the size and the charge of the amino acid at the position D1-257 play a role in PS II function by modulating the effective redox potential of the Q(B)/Q(B)(-) pair. We discuss an indirect mechanism mediated through electrostatic and/or surface charge effects and the possibility of more pleiotropic effects arising from decreased stability of the D1/D2 and D1/CP47 interfaces.

The effect of changing technique, dose, and PTV margin on therapeutic ratio during prostate radiotherapy.

PURPOSE: To quantify the dosimetric and radiobiological changes seen when using intensity-modulated radiation therapy (IMRT) or planning target volume (PTV) margin reduction with consistent planning parameters in a representative sample of localized prostate cancer patients. METHODS AND MATERIALS: Twenty patients were randomly selected from a cohort that received 79.8 Gy using six-field conformal radiotherapy. Using the clinical contours, PTV margin, planning system, and dose constraints, five-field IMRT plans were generated for 79.8, 83.8, and 88.0 Gy. The 88.0-Gy IMRT plan was then reoptimized with a PTV margin reduced to 3 mm. These plans were then compared using various dosimetric and radiobiological endpoints calculated for various alpha/beta. RESULTS: Intensity-modulated RT resulted in greater conformity to the PTV (p < 0.001). No improvement in mean normal tissue complication probabilities in the rectal wall (NTCPrw) was seen, and the modified therapeutic ratio (TR(mod)) was largely unchanged between six-field conformal and IMRT for the majority of the patients. When IMRT was used to escalate dose, NTCPrw increased by 9% at each 5% prescription increase (p < 0.001). Reducing the posterior PTV margin from 7 mm to 3 mm for an IMRT plan reduced the mean NTCPrw by 12% (p < 0.001) and resulted in a trend toward increased TR(mod)(p = 0.005). Changes in TR(mod) between conformal and IMRT planning or PTV reduction showed large interpatient variability. CONCLUSIONS: Changing from conformal to IMRT, or from PTV(10-7) to PTV(3), did not produce a uniform interpatient increase in TR(mod)when the CTV contained the prostate alone. Radiobiological benefits of these two methods seem to be dependent on the particular anatomy of individual patients, supporting the use of patient-specific margin, planning, and dose prescription strategies.

Marcus treatment of endergonic reactions: a commentary.

Two forms of the equation for expression of the rate constant for electron transfer through a Marcus-type treatment are discussed. In the first (exergonic) form, the Arrhenius exponential term was replaced by its classical Marcus term; in the second (endergonic) form, the forward rate constant was replaced by the reverse rate constant (the forward rate constant in the exergonic direction), which was expanded to an equivalent Marcus term and multiplied by the equilibrium constant. When the classical Marcus treatment was used, these two forms of the rate equation give identical curves relating the logarithm of the rate constant to the driving force. The Marcus term for the relation between activation free-energy, DeltaG#, reorganization energy, lambda, and driving force, DeltaG(o), derived from parabolas for the reactant and product states, was identical when starting from exergonic or endergonic parabolas. Moser and colleagues introduced a quantum mechanical correction factor to the Marcus term in order to fit experimental data. When the same correction factor was applied in the treatment for the endergonic direction by Page and colleagues, a different curve was obtained from that found with the exergonic form. We show that the difference resulted from an algebraic error in development of the endergonic equation.

Proton pumping in the bc1 complex: a new gating mechanism that prevents short circuits.

The Q-cycle mechanism of the bc1 complex explains how the electron transfer from ubihydroquinone (quinol, QH2) to cytochrome (cyt) c (or c2 in bacteria) is coupled to the pumping of protons across the membrane. The efficiency of proton pumping depends on the effectiveness of the bifurcated reaction at the Q(o)-site of the complex. This directs the two electrons from QH2 down two different pathways, one to the high potential chain for delivery to an electron acceptor, and the other across the membrane through a chain containing heme bL and bH to the Qi-site, to provide the vectorial charge transfer contributing to the proton gradient. In this review, we discuss problems associated with the turnover of the bc1 complex that center around rates calculated for the normal forward and reverse reactions, and for bypass (or short-circuit) reactions. Based on rate constants given by distances between redox centers in known structures, these appeared to preclude conventional electron transfer mechanisms involving an intermediate semiquinone (SQ) in the Q(o)-site reaction. However, previous research has strongly suggested that SQ is the reductant for O2 in generation of superoxide at the Q(o)-site, introducing an apparent paradox. A simple gating mechanism, in which an intermediate SQ mobile in the volume of the Q(o)-site is a necessary component, can readily account for the observed data through a coulombic interaction that prevents SQ anion from close approach to heme bL when the latter is reduced. This allows rapid and reversible QH2 oxidation, but prevents rapid bypass reactions. The mechanism is quite natural, and is well supported by experiments in which the role of a key residue, Glu-295, which facilitates proton transfer from the site through a rotational displacement, has been tested by mutation.