Everyone who is active in resuscitation teams will admit: treating a patient in cardiac arrest is a challenge and often things will not go as you would like them to. This can lead to negative feelings when the resuscitation attempt has ended, either because the patient did not regain return of spontaneous circulation (ROSC) or the patient is transported to the cath lab for example. Negative feelings can lead to a somewhat pessimistic attitude, especially when no progress is made to improve the quality of care. I think it is obvious we should avoid these things for many reasons. I am convinced that always debriefing you resus will make a positive impact on the quality of your resuscitations, the way your team members feel afterwards and the culture in your department. And it’s free. Dutch people love it when things are free.
Should we always debrief our cardiac arrests? I believe so. When you do not do it every time, you will miss opportunities to improve your system. But more importantly, when a case was really suboptimal, it is harder to get everyone together to debrief. I can remember working in an organization where debriefing was not standard. When after a case someone asked: “Shall we evaluate this case?” Team members were surprised, and perhaps also a little afraid. Someone reacted: “Why? Everything went all right don’t you agree?”. From that moment on I decided to make it standard. And not call it an ‘evaluation’ but debriefing.
I can also remember a prehospital case where the fire department was involved. From a medical point of view, it was a straightforward case (not a cardiac arrest). And it was not complex for the fire department either. Still, the fire chief came to us afterwards and asked us: was the information of the dispatch center clear? How were things on route to the incident? Were you satisfied cooperating with the fire department? And was communication optimal? We looked a little surprised when we heard all his questions but answered all of them. He could tell on the looks on our faces this we were not used to this so he explained: “If we are not able to manage these simple incidents perfectly, we will not be able to handle difficult incidents.” I knew he was right. It gave me the inspiration to debrief trauma cases even when there were no problems with the ABC’s. Debriefing should be standard. It allows you to get the basics right every time.
Getting all your team members together for a debriefing is one of the biggest challenges. Most of the time, people will come and go from the resuscitation room. After regaining ROSC, and being rushed to the ICU, CT, OR, and/or the cath lab, many of the team members from the initial resuscitation are not in the room. In this setting, I usually mention a certain time when we will try and be back at the Emergency Department to debrief the case. Most of the time, I get around 80% of the team members present. When the patient does not regain ROSC, the team is usually complete when the decision is made to stop CPR. I usually announce the standard debriefing shortly after stopping CPR. Sometimes even in the same room.
There are different ways to debrief a case. Most common ways are: having every one state one good thing and one way to improve, using a checklist or to reflect on the case in a chronological order. Having every one mention the two things has the advantage of relative short time needed and you getting to know the most important things to keep and to change. A checklist has the advantage of gaining information on specific elements which you might want to know on an organizational level but can sometimes limit a real dialogue between the team members. Going over a case in chronological order gives a structure and a complete overview but will not guarantee every one will say something. So every way has its advantages and disadvantages. I usually debrief according to the first method with a checklist afterwards to see if everything is covered.
One of the things I love about the debriefing is letting every one say something, including interns, guests and everyone else who was present at that case. It can give valuable insight into how things looked from a distance. This also can help break down hierarchy and create an atmosphere where everyone has the right to express his/her feelings. As a team leader, I think it is important to give compliments as well. Recently I had a case of cardiac arrest with severe hypothermia. During the code, one of the nurses reminded me of the implications for the resuscitation. Being busy getting the resus started, I did not think of this yet. During the debriefing, I gave a big compliment to her. She gave an example of high performance team membership.
During the debriefing things will be mentioned that need improvement. It is important to acknowledge these things and try to figure out ways to make that improvement. My mindset is: how can we prevent this from happening the next time, when other people form the resuscitation team? Make these improvements, if possible, as practical as can be. Usually I ask the person who mentioned the improvement to arrange it as well. And to let the team know if the improvement is made. In this way, you will experience a more constructive culture and, more importantly, the next patient will hopefully have a better chance of surviving their cardiac arrest.
Let’s debrief our resuscitations every single time. The best way is to agree on this on an organizational level but do not let this hold you back to start debriefing yourself. You can start with it today. I have experienced some great moments during debriefing and learned a lot. That is why I think we should debrief all our resuscitations. Missing a debriefing session is missing an opportunity to improve patient care. And it’s free!