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Three Part Question

For [emergency department staff, of all grades, involved in a traumatic resuscitation] does [a debriefing session vs no debriefing session] lead to a [reduction in stress and anxiety after the event leading to fewer days off sick, improved team work, improved moral and staff retention]

Clinical Scenario

A 14 year old boy was brought to the emergency department in cardiac arrest following a single stab wound to the chest. The team performed an emergency thoracotomy but unfortunately were unable to resuscitate the boy and he was declared dead in the department. Following this the large family who were present became very distressed and emotional scenes continued for many hours.

Due to the nature of the event there were large numbers of staff present who found the event very traumatic and discussion around the clinical decisions made continued for many days after. Following this event it was noted that some staff requested to not be placed in the resuscitation area and there were concerns that it increased sickness in the department.

Search Strategy

Medline (R) January 1946- search on 30th November 2018
Exp Critical incident stress debrief$
Exp Post traumatic stress disorder$ AND Exp Debrief$
Exp Moral Injury$
Exp Debrief$ AND Exp Emergency department personnel/ exp Emergency service hospital/ Emergency medical services/ Personnel, hospital
AND Stress disorder/ stress disorders, post traumatic
Limited to English Language and Humans

Search Outcome

4 relevant papers found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
N Nadir 2017 America	157 Residents in 4 Emergency departments in New York	Retrospective Survey	Real-time debriefing is of value in respect to education, systems and performance improvement	85.4% stated Time constraints as a Perceived barrier to debriefing being performed Perceived benefits in ascending order: 1. Venue for Learner and colleague feedback 65%, 2. Indentifies system errors 59% 3. Promotes team cohesiveness and unity 55% 4. Venue for colleague and learner performance gaps 54% 84% stated that debriefing occurred as a group 37.6% stated that debriefing included other professionals Only 15.3% reported that other specialities were involved. Most commonly debriefed events: Adverse events – 68.8% Emotionally upset colleagues 66.2% Miscommunications and poor team work 65.6%	Limited survey with only a 45-52% response rate. This low response rate may be an indicator that the residents surveyed do not class debriefing as an important aspect of their clinical care and professional development.
S. Ireland 2008 UK	144 paediatric emergency medicine and paediatric lead clinicians and lead nurses in both district general hospitals and teaching hospitals	Retrospective survey	Results of the study were used to formulate good practice guidelines, they conclude that there is limited research in this filed and recommend a multicentre study measuring hard outcomes rather than a survey.	Overall response rate 80% 72% of UK Trusts have no formal policy for carrying out debriefs 85% felt the aim of the debrief was to review and resolve medical, emotional and psychological issues around the resuscitation With 88% inviting doctors, 89% inviting nurses and 62% inviting other health care workers 69% would take place in the department where the resuscitation took place 76% are lead by someone involved in the resuscitation attempt 76% were involved in sessions that were lead by people who had not been trained in debriefing.	Paper only surveyed staff around failed paediatric resuscitation
S Healy 2012 Ireland	103 (90 nurses and 13 doctors) healthcare workers in Ireland	Retrospective survey	Debriefing is perceived as being an important aspect of emergency staffs coping mechanisms. Thus it should be delivered by a trained professional. All health professional should be given training about stress and stress reduction.	84% rated debrief as important or very important 62% stated they had never been offered an opportunity to take part in debriefing 15% did not know if debriefing was available to them Of those who had participated in debriefing 74% stated it occurred within 24 hours Most participants state debriefing takes place only after major trauma, paediatric or traumatic death, traumatic assault or sudden infant death syndrome. 97% stated the aim of debriefing was to provide staff with emotional or psychological support Of those who felt the primary aim was to improve team spirit
T Theophilos 2009 Australia and New Zealand	13 senior nurses and 13 senior doctors over New Zealand and Australia	Retrospective survey	Critical incident stress debriefing is regarded as important by emergency department workers and they intend to create guidelines based on this.	89% stated no specific ED guidelines on debriefing 62% debriefing facilitator would be from the hospital 89% stated the session was aimed a medical and emotional issues Form a scale of 0-10 with 10 being very important debriefing scored 8.2	Small sample size Only sampling senior clinicians would be interesting to have a spectrum of staff within the survey

Comment(s)

The pressure on emergency staff has never been higher with demands on the service increasing and flow out of the department decreasing. Staff within the emergency department are expected to manage these increases whilst still providing high quality care. Within these pressures we still have the high acuity patients in the resuscitation area which means staff are often expected to move straight to the next case following resuscitation. This may lead to increased stress levels and symptoms of burn out. Research into critical incident stress debriefing for victims of trauma and disasters has had mixed results and there is little evidence to support its use. The stresses and emotions of a victim of trauma are different to those of a worker who experiences a difficult case at work and thus it is difficult to transfer research over. The above surveys are based over many different countries and over both adult and paediatric departments. They indicate that there is a desire for debriefing to happen but in practice it rarely does and few departments have guidelines in place to facilitate this. The surveys state that a debrief is seen as an opportunity to both learn from the event and to also defuse any emotions or anxiety created by the event. It is important to note that there may be an element of selection bias here as people who agree with debriefing may be more likely to complete a survey about it. The research states that the most common things to be debriefed over are paediatric deaths, buns and traumatic events. However I would argue that for debriefing to become the norm and to help people develop coping strategies as both a team and as individuals it should be done more often and offered frequently. There is no research done into staff sickness, moral and staff retention with the introduction of team debriefing. Nadir et al. found that the residents that they surveyed felt that debriefing promotes team cohesiveness but no other papers mention team working. Within the simulation world work has been done around the benefits of team debriefing to aid learning from the event, but this work has not been replicated in the ‘real’ world. Ireland et al. stated that 76% were lead by someone involved in the resuscitation and that 76% were not trained in leading a debriefing session. Theophilos et al. also stated that 62% would be from the hospital. There is no further comments as to whether the staff felt these were appropriate people to lead the debrief. I think it is important to remember here that the person leading the debrief may also need some emotional help no is immune to stress. With this in mind it may be helpful for the debriefing lead to have not been involved in the resuscitation.

Clinical Bottom Line

There is limited evidence to support the development of team debriefing in the emergency department, with no research into staff moral and days of sickness saved, however there is no evidence that it does harm and a pool of evidence stating staffs desire for it to exist.

References

1. Nur-Ain Nadir, Suzanne Bentley, Dimitrios Papanagnou Characteristics of Real-Time, Non-Critical Incident Debriefing Practices in the Emergency Department Western Journal of emergency medicine (2017) 18(1);146-151
2. S Ireland, J Gilchrist, I Maconochie Debriefing after failed paediatric resuscitation: a survey of current UK practice Emergency medical Journal (2008) 25;328-330
3. Sonya Healy and Mark Tyrrell Importance of debriefing following critical incidents Emergency Nurse (2013) 20(10);32-37
4. Theane Theophilos, Joanne Magyar and Franz E Babl Debriefing critical incidents in the paediatric emergency department: Current practice and perceived needs in Australia and New Zealand, Emergency medicine Australasia (2009) 21;479-483