Setting. Cohen Children’s Medical Center (New Hyde Park, NY) is a 200-bed, free-standing, quaternary care academic facility that serves patients from around the region, nation, and globe. The 57-bed, neonatal intensive care unit (NICU) and 34-bed pediatric intensive care unit (PICU) are state-of-the-art facilities serving children with the most complex conditions, offering extracorporeal membrane oxygenation (ECMO), therapeutic hypothermia, and innovative cardiac, neurologic, and orthopedic surgery. Extensive bone marrow transplant, cancer, organ transplant, and level 1 trauma patients are routinely treated on the medical floors and intensive care units (ICUs).
History of preventive concern (2012-2013). Children’s Hospitals Solution for Patients Safety (CHSPS) national network was launched in 2011. The goal of this initiative was to prevent hospital-acquired harmful conditions through the use of standard definitions; training in the Model for Improvement and Plan/Do/Study/Act cycles8,9; the creation, implementation, and measurement of event prevention bundles; data analysis; and transparency across the collaborative. In 2012, Cohen Children’s Hospital became the first pediatric hospital in New York state to join CHSPS. The program was awarded a multiyear contract by the CMS as part of its Partnership for Patients initiative, a priority project designed to reduce hospital inpatient harm by 40% over a 3-year period. A new safety program, “Commit to Zero,” that addresses reducing errors to none, was introduced; it includes implementing daily safety briefings, safety behavior education, leadership rounding, a “Great Catch” employee recognition program, development of hospital-acquired condition (HAC) teams, and a safety coach program. In this framework, a PU HAC team was created and a PU Prevention Bundle was developed and propagated throughout the hospital.
Before the team’s formation, surveillance of PUs and data collection were inconsistent. Five (5) random, 1-day studies revealed a PU prevalence of 3% on medical floors, 15% in critically ill pediatric patients, and 8% in the neonatal unit. Prevalence was calculated by dividing the total number of hospital-acquired PUs by the total number of patients surveyed times 100. Total rate of PUs (total PU per year/total number of admissions) was 0.0069 for 2013 (likely underreported because data collection was inconsistent).
PU Prevention Bundle. The PU Prevention Bundle focused on the National Pressure Ulcer Advisory Panel (NPUAP) recommended elements10: skin assessment, repositioning, device rotation, bed support surfaces, moisture management, and nutrition. All nursing staff were required to complete mandatory education modules presented as didactic lectures and computerized webinars with postlecture tests that addressed skin assessment scales, PU staging, risk, prevention, management, and bundle element documentation. Random patients’ computerized records were reviewed for each bundle element. The bundle review sheet, completed and assessed by PU HAC co-leads, revealed inconsistencies in implementation and documentation of bundle elements stemming from suboptimal knowledge of PU prevention strategies, staging, and treatment. According to the subjective opinion of the co-leads after interviewing staff, staff were hesitant to report PUs; thus, reports were not timely or accurate. As a result, opportunities for prevention often were missed.
Evaluation of gaps (2013). In order to accomplish the primary goal of PU/PI reduction, the members of the PU HAC group developed a key driver diagram (see Figure 1), identifying 4 primary drivers: prevention process, accurate recognition, timely and accurate reporting, and change of culture. Didactic lectures and mandatory computer presentations were recognized by the PU HAC co-leads and nursing education leadership as ineffective in bridging theoretical knowledge with practical care. Most nurses did not feel comfortable implementing preventive measures, staging, diagnosing, and treating PUs, despite the initial wave of mandatory education. Many staff members, including nurses and clinicians, were complacent about existing injuries. A culture of prevention, urgency of reporting, and preoccupation with harm was not prevalent. Some staff did not feel comfortable reporting PUs, fearing punitive reaction and blame.
The team’s evaluation of existing practices as part of subjective discussion between nursing education leadership, quality departments, and the PU HAC co-leads suggested a need for a different approach that tied all driver elements together in a safe but realistic environment.
As evidenced by the lack of information in the literature prior to 2014, quality improvement is a relatively new concept for medicine in general and very new to PI specifically. In the past, quality was generally defined as achieving best clinical outcomes and safety was defined as not harming patients; however, these concepts have converged over the last decade and the idea of “aiming for zero harm” has emerged.9,11 According to a review of descriptive studies discussing core concepts of quality improvement and patient safety,11 3 key principles are required for achieving zero harm: development of safety culture, staff accountability, and transparency. Simulation-based or event-based medical education has been shown in reviews of descriptive core concepts and studies involving on medical simulation12-14to be useful for creating a safety culture in events of critical resuscitations, trauma, and negative surgical scenarios. Appropriate feedback (including debriefing) has been shown to be central to this process.13-15Because no literature was available that described the role of debriefing in PU reduction, our group borrowed the concept of simulation and debriefing from industries such as aviation, automotive, and trauma where it had been used successfully.12,13,16
Conceptual framework — debriefing. Feedback is a post-experience analytic process. It involves discussion and analysis of an experience and reviewing and integrating lessons learned into one’s knowledge bank. A review of the literature12 shows that in adult teaching, “active” participation is an important factor in effective learning. Critical learning is achieved by reflecting on experiences, recognizing strengths and weaknesses, and reviewing alternative choices. Feedback is an integral part of medical debriefing.12
Debriefing is defined by Merriam-Webster as questioning someone about a completed mission with an aim of obtaining useful information. Generally, it is a process of inquiry and evaluation. First developed as a formal process in the military during World War II when troops were gathered after missions to reconstruct and describe what happened in an effort to reduce psychological stress,12 post combat discussions or “performance critiques” eventually became a fundamental component of battle simulation exercises for soldiers in training.12,13 The focus of after-action reviews shifted over time from subjective emphasis on error identification to nonpunitive guided group discussions and self-reflection. Debriefing also has deep roots in aviation, mass transportation, and nuclear power, areas in which overt or latent human and system weaknesses can lead to loss of life.13 As a result, it appears these industries have developed cultures of safety that are far less tolerant of conditions that place human lives at risk than are prevalent in the health care industry.
A relevant review found effective communication is crucial to patient safety.16 The Joint Commission found communication failures are the root cause of 60% to 70% of sentinel events. In health care, it is important to find ways to open lines of communication. Post-event debriefings in medicine are defined as a “discussion of actions and thought processes after an event to promote reflective learning and improve clinical performance”; they are facilitated discussions of a clinical event focusing on learning and performance improvement.16 Essential elements of post-event debriefings include active self-learning, a primary intent for improvement, reflection on specific events, and the inclusion of input from multiple team members.14 Post-event debriefings are a foundational behavior of high-performing teams.16
The American Heart Association endorses debriefing as a strategy to improve cardiopulmonary resuscitation quality.15,16 A recent meta-analysis11,17 found organizations can improve individual and team performance by up to 25% by conducting effective debriefings; in these simulation-based studies, debriefing has been associated with enhancements in team performance and improvements in both technical and behavioral skills. In clinical medicine, post-event debriefings have been shown to increase overall performance, reduce the frequency of equipment-related problems, and improve communication and teamwork.
Debrief Tool (2013–2014). The PU HAC lead (an intensive care attending physician) developed the “PU Occurrence Debrief” tool, a 1-page summary to guide a discussion after PU events in real time led by PU HAC leads (see Figure 2). A frequent attendee of post event debriefs, she searched the literature for information on safety approaches, adult learning, and debriefing specific to medicine and applied the concept to PU staff education and management. She presented her instrument to the group, her co-lead, and a quality partner, and the tool was trialed in a few pilot instances where the concept was well-received. Staff were supportive and appreciative of the framework for discussion. Concomitantly, staff were re-educated on the reporting process via an electronic medical database, with emphasis on time (goal to report within 12 to 24 hours), accuracy, and completeness.
Debrief process. The PU implemented debrief process is triggered by assistant nurse managers on each unit, who report each event via a centralized computerized system. These reports are transmitted to a quality department member and to the PU HAC lead. The PU HAC lead then conducts the debrief with the team taking care of the affected patient within 24 to 48 hours of the occurrence. This short gap serves to minimize recall bias, allowing timely patient care and potentially addressing global issues such as equipment failure, gaps in communication, lack of support, or staffing problems. To improve team performance, all members of the team who are physically present participate in the post-event debriefing. The goal is to include all staff, patient, and/or family if appropriate, because each offers a unique perspective and each perspective is important to understanding the individual and team strengths and weaknesses.
Three (3) stages of debriefing process are described in literature12:
Stage 1: The reaction phase: Allow for initial responses. Summarize what happened. Ensure common understanding.
Stage 2: The understanding phase: the heart of the debriefing inquiry and analysis. Inquire about assumptions/actions.
Stage 3: The summary phase: Lessons learned. Provide take-away points for the future as soon as possible after the event to review the facts, identify system errors, and improve the process with goals to reduce future recurrences.
We found debriefing to be the most effective when structured and facilitated. This structure is based on the “Gather, Analyze, Summarize” approach to debriefing endorsed by the American Heart Association and incorporated in its life support courses.17 We begin by reviewing the details of the event, examining the patient and discussing staging accuracy. This is followed by discussion of the risk factors, mitigating circumstances, presence or absence of preventive measures, and the nature of treatment to minimize sequelae. Finally, a summary or a simulation for the next time is generated, with emphasis on “What would I do next time?” We try to empower staff to speak frankly and offer their opinions and suggestions. The atmosphere of psychological safety, where team members feel secure in critically analyzing their own performance, is best achieved when the debriefing proceeds in a nonpunitive fashion. We focus on high-value issues such as adherence to prevention guidelines, equipment or assessment issues, and appropriateness of treatment. Debriefing is kept brief, taking no more than 10 minutes.
Bundle implementation and tracking. The consistency of bundle element implementation and documentation has been tracked since 2014. Random audits of electronic PU/PI prevention documentation are performed every quarter (5 patients are selected from every unit) by PU HAC champions and documented on a PU HAC Bundle Audit sheet; the audits focus on completeness, accuracy, meaningful interventions based on the assessed risk, and (if the patient develops a PU/PI) accuracy and timing of the reporting. Audit questions require Yes/No responses (eg, Performed vs. Not performed, Interventions documented vs. Not documented, based on the patient’s clinical risk). When the audit is complete, the patient PU/PI assessment score as well as clinical risk is determined by the auditors first and then compared to the documented data. The PU/PI champions are well-trained and are able to assess the accuracy of the bedside nurses’ clinical judgment.
Data collection and analyses. The primary outcome was total number of hospital-acquired PUs/PIs per year. New PUs/PIs occurring after admission were counted and prevalence was calculated as the number of PUs/PIs divided by the total admissions per year. Key process measures (bundle compliance, preventive measures implementation, and timeliness and accuracy of the PU/PI incident report) were assessed quarterly via random patient audits and documented in a hospital-based Health Insurance Portability and Accountability Act-compliant database via a computerized data collection tool.