Debrief to Learn: Learn to Debrief

Objectives: 1. Describe role of debriefing in simulation-based education. 2. Identify debriefing techniques in simulation. 3. Describe settings/situations appropriate for debriefing

Team training: implications for emergency and critical care pediatrics.

PURPOSE OF REVIEW: The field of team training is quickly evolving and data are emerging to support the close relationship between effective teamwork and patient safety in medicine. This paper provides a review of the literature on team training with specific emphasis on the perspectives of emergency and critical care pediatricians. RECENT FINDINGS: Errors in medicine are most frequently due to an interaction of human factors like poor teamwork and poor communication rather than individual mistakes. Critical care settings and those in which patients are at the extremes of age are particularly high-risk, making emergency and critical care pediatrics a special area of concern. Team training is one approach for reducing error and enhancing patient safety. Currently, there is no single standard for team training in medicine, but multiple disciplines, including anesthesiology, emergency medicine and neonatology, have adapted key principles from other high-reliability industries such as aviation into crisis resource management training. SUMMARY: Team training holds promise to improve patient safety in pediatric emergency departments and critical care settings. We must carefully delineate the optimal instructional strategies to improve team behaviors and combine these with rigorous outcomes assessment to diagnose team problems and prescribe targeted solutions, and determine their long-term impact on patient safety

Patient Handoffs: Is Cross Cover or Night Shift Better?

OBJECTIVES: Studies show singular handoffs between health care providers to be risky. Few describe sequential handoffs or compare handoffs from different provider types. We investigated the transfer of information across 2 handoffs using a piloted survey instrument. We compared cross-cover (every fourth night call) with dedicated night-shift residents. METHODS: Surveys assessing provider knowledge of hospitalized patients were administered to pediatric residents. Primary teams were surveyed about their handoff upon completion of daytime coverage of a patient. Night-shift or cross-covering residents were surveyed about their handoff of the same patient upon completion of overnight coverage. Pediatric hospitalists rated the consistency of information between the surveys. Absolute difference was calculated between the 2 providers\u27 rating of a patient\u27s (a) complexity and (b) illness severity. Scores were compared across provider type. RESULTS: Fifty-nine complete handoff pairs were obtained. Fourteen and 45 handoff surveys were completed by a cross-covering and a night-shift provider, respectively. There was no significant difference in information consistency between primary and night-shift (median, 4.0; interquartile range [IQR], 3-4) versus primary and cross-covering providers (median, 4.0; IQR, 3-4). There was no significant difference in median patient complexity ratings (night shift, 3.0; IQR, 1-5, versus cross cover, 3.5; IQR, 1-5) or illness severity ratings (night shift, 2.0; IQR, 1-4, versus cross-cover, 3.0; IQR, 1-6) when comparing provider types giving a handoff. CONCLUSIONS: We did not find a difference in physicians\u27 transfer of information during 2 handoffs among providers taking traditional call or on night shift. Development of tools to measure handoff consistency is needed

Diagnosis of a craniopharyngioma after acute brainstem herniation in an emergency department.

A 9-year-old previously healthy girl presented with 3 weeks of intermittent emesis and headache to a community emergency department, where she had rapid decompensation due to increased intracranial pressure. Head computed tomography revealed a calcified suprasellar mass consistent with a craniopharyngioma. Despite medical and surgical intervention, the patient had progression of herniation with global cerebral infarction, and care was withdrawn. Although craniopharyngiomas are typically thought to be benign, slow-growing intracranial tumors, this case emphasizes the need for an expeditious diagnostic evaluation when symptoms that may be referable to intracranial hypertension are evident. Craniopharyngiomas and emergency management of intracranial hypertension are reviewed

Admission handoff communications: clinician\u27s shared understanding of patient severity of illness and problems.

OBJECTIVE: Communication errors are a leading cause of medical mistakes. Handoff communications during the admission of a patient are a critical point of communication during which patient care is transferred from one clinician to another. The transmission of the patient\u27s current severity of illness and active problems is integral to this communication. Our objective was to determine if this information is conveyed by the current handoff process between resident physicians. METHODS: We recorded admission handoff communications between residents and then asked each resident to independently rate the patient\u27s severity of illness and to list the patient\u27s problems. The scores and lists were compared for agreement. Attending physicians listened to the recordings and also assessed severity of illness and patient\u27s problem lists. RESULTS: Three quarters of the handoffs had agreement about the severity of the patient\u27s illness. However, there was low agreement about the most severe problem and the total problem lists between residents involved in the handoff communication. Attending physicians were able to identify more patient problems. CONCLUSIONS: We conclude that information needed to assess the patient\u27s severity of illness and problems may have been present in the handoff communications but may not have been fully received and integrated by the residents. In addition, attending physicians may have an additional capacity to infer information, perhaps because of prior clinical experience or expertise. This study implies that residents may need more formal education, training, and evaluation of their handoffs to improve patient safety