Written by: Diana Halloran (NUEM ‘24) & Andrew Long (NUEM ‘25) Edited by: Nick Wleklinski (NUEM ‘22)
Expert Commentary by: John Bailitz, MD
Introduction
The Emergency Department is a challenging work environment for a variety of reasons. It is not surprising that unpredictable work hours mixed with frequent interactions with patients undergoing physical and emotional trauma can cause spillover into the personal lives of ED staff. However, in the recent years there has been an increasing body of literature that highlights the challenges that we face as ED personnel.
The American Heart Association even recommends a “hot” debrief for every cardiac arrest attended by a healthcare professional. We know debriefing has concrete and tangible advantages. Previous studies have shown that debriefing immediately after an event can improve individual and team performance by 20-25%, issues can be identified for interventions, and mental health and emotional trauma can be addressed. It is well-documented that ED physicians have historically high rates of burnout compared to other specialties as well as a high incidence of post-traumatic stress disorder (PTSD) compared to the general population. PTSD is 2 times more prevalent in physicians (14.8%), with EM resident physicians falling in the range from 11.9%-21.5%.
As a field, we are now starting to design and implement interventions to preserve our own mental wellbeing. In fact, debriefing has been shown to be one method for managing PTSD. One article described an initiative that implemented an immediate (also known as “hot”) debrief protocol immediately following all cardiac arrests during which 90% of participants felt they benefited psychologically, and 100% felt it improved their clinical practice. In this post, we will give a brief overview of a landmark study in the ED debrief literature, which advocates for a “hot” debrief model in resuscitation cases using the STOP5 model.
Study Analysis
This study published in 2019 designed, tested, and developed the STOP5 model to facilitate safer patient care, team development, and quality improvement within the Emergency Department. The STOP5 model, the first widespread debriefing tool, was designed as a “hot debrief”: “an interactive and structured team dialogue that takes place either immediately or very shortly after a clinical case”. Any team member of the resuscitation may lead the hot debrief.
Figure 1: The STOP5 Model Debriefing Framework (proposed by CA Walker et al 2020)
After an initial check-in the team moves to a group discussion and follows the STOP framework above: Summarize the case, Things that went well, Opportunities to improve, and Points to action and responsibilities. Inclusion criteria for these hot debriefing cases were major traumas, deaths in resuscitation, and any cases upon request by any staff member. No potential resuscitation cases were formally excluded.
After 18 months the ER staff was re-surveyed to ascertain STOP5 rating scores, the number of staff involved in the debriefs, any possible benefits or barriers to team performance, and if staff believed there should be more or less hot debriefing in the ER. In this 18-month review all STOP5 debriefs were rated “good” to “excellent”, suggesting the debriefing was highly valued. 98% of respondents believed that there should continue to be more hot debriefs in the emergency department. In a 12-month review there were 10 process and equipment changes (“hard outcomes”) as a direct result of the STOP5 hot debriefs and 14 additional opportunities for improvement. The hot debrief allowed for concrete actions to be taken about these issues and for a dedicated plan of action for correction. These hard outcomes identified issues such as those listed below which allowed for concrete solutions for all the identified problems.
Shortage of resuscitation room equipment
Drug stocking issues
Drug preparation/infusion regime for vital but rarely used medications difficult for staff to find
Faulty equipment (doors, machines)
Reported barriers to enacting hot debriefs include time constraints, workload, low staff confidence in leading the debrief, or absence of team members (consultants who might have left the department, change of shift). For these reasons hot debriefing is still not standard practice. However, a hot debrief such as STOP5, with a concrete checklist, is an inexpensive and quick way to enhance team performance, improve patient care, and assist with emotional trauma and mental check-ins for the team. Debriefing is a valuable and important aspect of our medical career. We hope to bring more of a focus to debriefing within our institution by beginning to enact the STOP5 based hot debriefing after clinical events.
Expert Commentary
Whether working in a community or academic Emergency Department, recurrent extraordinary cases threaten the well-being of the clinical team during that shift and after. Although resources often exist for individual employee assistance after a difficult shift has ended, few interventions have been described to help the team regroup and recover during that particular shift. Furthermore, department level morbidity and mortality conferences or hospital level quality assurance reviews focus more on the technical case details and less on team wellness.
With the primary purpose of quickly restoring team performance and wellness, hot debriefs at NUEM provide the opportunity for our ED teams to have a structured yet brief meeting immediately after an extraordinary case. Using STOP5, team leaders have a step-by-step plan to quickly yet effectively help every clinician on the team properly mentally frame the case, share gratitude, and then identify and assign opportunities for immediate improvement. Building on life support courses and residency training, specific education on the STOP5 framework quickly prepares senior clinicians to lead hot debriefs. Utilizing change management principles to identify and address logistical barriers helps to create a culture that supports immediate debriefing. Successful strategies in our NUEM ED include protocols to pause new inflow and cover existing patient demands, designating meeting spaces, adding positive program reminders to clinical areas and recurring meetings, and tracking and celebrating program success.
References
1. Get With The Guidelines - Resuscitation Clinical Tools. (2021, August 16). Www.Heart.Org. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-resuscitation/get-with-the-guidelines-resuscitation-clinical-tools
2. Gilmartin, S., Martin, L., Kenny, S., Callanan, I., & Salter, N. (2020). Promoting hot debriefing in an emergency department. BMJ Open Quality, 9(3), e000913. https://doi.org/10.1136/bmjoq-2020-000913
3. Tannenbaum, S. I., & Cerasoli, C. P. (2012). Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors: The Journal of the Human Factors and Ergonomics Society, 55(1), 231–245. https://doi.org/10.1177/0018720812448394
4. Vanyo, L., Sorge, R., Chen, A., & Lakoff, D. (2017). Posttraumatic Stress Disorder in Emergency Medicine Residents. Annals of Emergency Medicine, 70(6), 898–903. https://doi.org/10.1016/j.annemergmed.2017.07.010
5. Walker, C. A., McGregor, L., Taylor, C., & Robinson, S. (2020). STOP5: a hot debrief model for resuscitation cases in the emergency department. Clinical and Experimental Emergency Medicine, 7(4), 259–266. https://doi.org/10.15441/ceem.19.086
John Bailitz, MD
Vice Chair for Academics, Department of Emergency Medicine
Professor of Emergency Medicine, Feinberg School of Medicine
Northwestern Memorial Hospital
How To Cite This Post:
[Peer-Reviewed, Web Publication] Halloran, D. Long, A. Wleklinski, N. (2022, Sept 12). Debriefing in the ED. [NUEM Blog. Expert Commentary by Bailitz, J]. Retrieved from http://www.nuemblog.com/blog/debriefing-ED
