Critical incident debriefing toolkit: 2: How to hot debrief

Abstract
What we already know about this topic: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation.

What this article tells us that is new: Failure to debrief after critical events is common among anesthesia trainees and likely anesthesia teams. Communication breakdowns are associated with a high rate of the failure to debrief.

Background: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors' objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel.

Methods: At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings.

Results: During a 1-yr period, 89 critical events were identified. The overall debriefing rate was 49% (44 of 89). Nearly half of events occurred outside the operating room. Events included crisis events (e.g., cardiac arrest, difficult airway requiring an urgent surgical airway), disruptive behavior, and critical communication breakdowns. Events containing critical communication breakdowns were strongly associated with not being debriefed (64.4% [29 of 45] not debriefed in events with a communication breakdown vs. 36.4% [16 of 44] not debriefed in cases without a communication breakdown; P = 0.008). Interview responses qualitatively demonstrated that lapses in communication were associated with enduring confusion that could inhibit or shape the content of discussions between involved providers.

Conclusions: Despite the value of proximal debriefing to reducing provider burnout and improving wellness and learning, failure to debrief after critical events can be common among anesthesia trainees and perhaps anesthesia teams. Modifiable interpersonal factors, such as communication breakdowns, were associated with the failure to debrief.

Abstract
In a 2016 survey of workforce trends, Deloitte found the single greatest change in the way organisations work is an increasing reliance on teamwork. While an interesting trend overall, teamwork is nothing new to healthcare, let alone the perioperative context that relies heavily on effective coordination both within and between often dynamic teams. When teams work effectively, patients benefit from higher quality of care, the medical system runs more efficiently, and medical staff experience lower levels of stress5,6. While many team-enhancing practices exist3, few have been empirically demonstrated to yield increases in individual and team performance to the extent of debriefing. The secret? Debriefing enhances individual and team learning which in turn fosters the systematic translation of those learnings into actions that ultimately results in positive outcomes such as enhanced patient care. When teams debrief they are investing in their future, not just as a team but also as individuals working in a highly complex and unpredictable context where the stakes often could not be higher. However, despite their potency and widespread use in other high-risk industries, debriefings are largely underutilised in the medical context.

Abstract
Steelman (2014) stated that the concept of briefing and debriefing used in operating theatres derived from the airline industry in the 1970s. There had been a series of devastating air crashes and the airline industry had come under severe public scrutiny. Investigations identified that, while the crews operating these aircrafts were very skilled and knowledgeable, they lacked competence in their ability to perform as part of a team.

Abstract
This survey investigated the need, and the availability, of debriefing after critical incidents for training anaesthetists. A cross-sectional postal survey of all Australian anaesthetic trainees was conducted in May 2002. Four hundred and nineteen responses were analysed (response rate 64%). Debriefing after a critical incident was perceived by most trainees to be useful, however 36% (n = 149) had never been debriefed. Trainees ranked their preferred content for a debriefing as 'anaesthetic issues' followed by the 'psychological impact of the incident' 'patient issues' and 'surgical issues'. Almost half of respondents reported that they did not feel supported by their anaesthetic department after a negative outcome incident. Trainees who had debriefings were more likely to feel supported by senior colleagues. Debriefing after critical incidents should be an integral part of the supervision of anaesthetic trainees.