Debriefing Gold: Harnessing the Power of Debriefing Data to Inform Education.

Debriefing is a critical element in healthcare, both in the clinical environment and in the simulation lab. Often, what is said at a debriefing is not recorded, leading to loss of critical data that could be used to inform future simulations, education, and systems improvement. In this perspective piece, we explain the powerful role that capturing debriefing data can have for identifying themes to improve learners' knowledge and skills, as well as inform data-driven systems change and initiatives.

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.

BACKGROUND: Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location. METHODS: Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medication, resource/system, or technical skill categories. A hazard matrix was used by multiplying occurrence frequency of LST in simulation and real clinical events (based on expert opinion) and severity of the LST based on agreement between two evaluators. RESULTS: Seventy-four in situ cardiac arrest simulations were conducted hospital wide. Hundreds of safety threats were identified, analyzed, and categorized yielding 106 unique latent safety threats: 21 in the equipment category, 8 in the medication category, 41 in the resource/system category, and 36 in the technical skill category. The team worked to mitigate all LSTs with priority mitigation to imminent risk level threats, then high risk threats, followed by non-imminent risk LSTs. Four LSTs were deemed imminent, requiring immediate remediation post debriefing. Fifteen LSTs had a hazard ratio greater than 8 which were deemed high risk for remediation. Depending on the category of threat, a combination of mitigating steps including the immediate fixing of an identified problem, leadership escalation, and programmatic intervention recommendations occurred resulting in mitigation of all identified threats. CONCLUSIONS: Hospital-wide in situ cardiac arrest team simulation offers an effective way to both identify and mitigate LSTs. Safety during cardiac arrest care is improved through the use of a system in which LSTs are escalated urgently, mitigated, and conveyed back to participants to provide closed loop debriefing. Lastly, this hospital-wide, multidisciplinary initiative additionally served as an educational needs assessment allowing for informed, iterative education and systems improvement initiatives targeted to areas of LSTs and areas of opportunity.

Stroke Code From EMS to Thrombectomy: An Interdisciplinary In Situ Simulation for Prompt Management of Acute Ischemic Stroke.

INTRODUCTION: Treatment of acute ischemic stroke is challenging because it requires prompt management, interdisciplinary collaboration, and adherence to specific guidelines. This resource addresses these challenges by providing in situ simulated practice with stroke codes by practicing clinicians at unannounced times. METHODS: An emergency department team was presented with a 55-year-old simulated patient with speech difficulty and right-sided weakness. The team had to assess her efficiently and appropriately, including activating the stroke team via the hospital paging system. The stroke team responded to collaboratively coordinate evaluation, obtain appropriate imaging, administer thrombolytic therapy, and recognize the need for thrombectomy. Learners moved through the actual steps in the real clinical environment, using real hospital equipment. Upon simulation completion, debriefing was utilized to review the case and team performance. Latent safety threats were recorded, if present. Participants completed an evaluation to gauge the simulation's effectiveness. RESULTS: Six simulations involving 40 total participants were conducted and debriefed across New York City Health + Hospitals. One hundred percent of teams correctly identified the presenting condition and assessed eligibility for thrombolytic and endovascular therapy. Evaluations indicated that 100% of learners found the simulation to be an effective clinical, teamwork, and communication teaching tool. Debriefing captured several latent safety threats, which were rectified by collaboration with hospital leadership. DISCUSSION: Impromptu, in situ simulation helps develop interdisciplinary teamwork and clinical knowledge and is useful for reviewing crucial times and processes required for best-practice patient care. It is particularly useful when timely management is essential, as with acute ischemic stroke.

Multidisciplinary management of ventilator weaning and tracheostomies for COVID-19 patients at a major NYC public hospital: A blueprint for other institutions.

At the height of the coronavirus pandemic in New York City, at our hospital (NYC Health/Hospitals-Elmhurst) 95% of inpatients tested positive for COVID-19 and it operated at 500% surge ICU capacity-one of the greatest impacted centers in the nation. In the face of this we established a systematic multidisciplinary approach to manage ventilated ICU patients and select those appropriate for tracheostomy. Members from Pulmonary Critical Care, Anesthesiology, Surgery, Ethics, and Otolaryngology, created a protocolized way to assess all ICU patients in our hospital and, if deemed appropriate, help them towards weaning or tracheostomy and subsequent discharge. Given the climbing COVID numbers throughout the nation, and once again in NY, we believe sharing our protocol and brief outcomes will be very helpful for hospitals who are struggling with what we did, as it may serve as a blueprint for these institutions.

A Simulated Mass Casualty Incident Triage Exercise: SimWars.

Introduction: This multipatient simulation exercise encompasses triage by hospital medical providers during a mass casualty incident (MCI) involving gas line explosion with building collapse. The SimWars format allows two teams to participate in identical simulations coupled with active audience observation, followed by facilitated group discussion. The exercise requires real-time knowledge application of MCI management and helps learners develop a framework for rapidly classifying and dispositioning MCI patients. Methods: Two teams of provider pairs completed MCI triage of 12 simulated patients in 8 minutes with an objective of quickly and accurately dispositioning within hospital bed availability. Participants included emergency medicine and surgery physicians, with active observation by mixed provider audiences. Observers completed a checklist per patient (category: urgent/emergent/not emergent, disposition: bed type/location). At simulation conclusion, a 45-minute facilitated discussion compared observers' self-assessment of MCI patient management with the simulation teams' decisions. Finally, an expert panel discussed management decisions and MCI triage pearls. Results: Team performances (N = 4) and audience responses (N = 164) were similar on seven of 12 patients, allowing robust discussion. Participants completed an evaluation at exercise conclusion; 37% reported good/excellent ability to accomplish MCI initial triage and disposition before this exercise compared to 100% after, a statistically significant 63% increase. All postsurvey respondents agreed or strongly agreed that the exercise would change their MCI clinical practice. Discussion: The two-team format allows comparison of how different teams handle MCI triage, and active observation allows comparison of audience and team decision making.