75. Hot Debriefing | Processing events while you’re still in the arena

Finding time to debrief challenging cases can feel nearly impossible amidst the tumult and task saturation of medical practice. The reality, however, is that it’s a necessity, not a nicety.  In this episode, emergency physician Stuart Rose and rescue specialist Ashley Liebig discuss two different approaches to immediate debriefs: INFO and the hot offload.  

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Guest Bios: 

Stuart Rose is an emergency physician practicing in Calgary, Canada and lead author of the seminal debriefing paper, Charge nurse facilitated clinical debriefing in the emergency department. 

Ashley Liebig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response

We Discuss

Rob describes a particularly stressful resuscitation that was taxing, emotionally and physically, and shares his approach to the “hot offload” [03:30];

• This resuscitation went on for hours and hours.  Everyone was stressed.  Ultimately, the patient died, leaving them feeling low.  This was one of Rob’s most challenging resuscitations, and he was lucky to have been working with the “A team”.  They communicated well and shared ideas.  Nonetheless, Rob felt doubt — in his ability and in himself as an emergency physician.  
• Rob needed to “hot offload”.  He gathered the whole team together and said, “I want to debrief.  We need to offload what just happened, because I think we’re all tired, stressed, and depleted.”  He started by sharing how he was feeling, and then went around the room asking for feedback.  It was almost like free association from everybody who had participated.  Rob commended the team on their fantastic work, but he left the room wondering, “Was that good?  Was that bad?  How are debriefings supposed to go?”  
• When debriefing, open the conversation up to the whole team, making it an interprofessional experience. Share your own experience and be humble in what happened.  That sets a tone for the rest of the group to feel comfortable revealing what they were feeling as well.  
• Having the team lead go first in the debriefing is not always a good idea.  It can set up a power dynamic, and there might not be as much honesty.  The leader can go first as long as he/she is respected and known to be genuine and interested in how the rest of the team feels.

Debriefing core concept #1:  The ED charge nurse is optimally suited to organize the debriefing and to lead the conversation [07:25];

• If making a debriefing happen is left up to the physician, it is less likely to occur because of his/her constant state of task saturation. By the time the physician has time to debrief, other members of the team are often off duty.  
• Somebody else needs to take on the responsibility of creating the opportunity for the debriefing to take place. Charge nurses are ideal in this role as they know the staff, understand the logistics of the department, and typically don’t have other patient responsibilities.  They’re the mainstay of the ED, and well-versed at being leaders.
• Quoting from Rose’s paper:  “ED charge nurses have clinical knowledge, operational awareness, and an understanding of team roles and expertise within their departments.  They usually observe resuscitations, but are not allocated to a specific role, so are more situationally aware and ideally suited to facilitate post-event debriefings.”
• Debriefing core concept #2 is the basic assumption. The ‘basic assumption’ sets the tone for the conversation:  everyone caring for the patient is intelligent, capable, and wants to do their best and improve.

A structured approach to debriefing using the mnemonic INFO [12:40];

• A structured method makes it easier for novice facilitators to take on this responsibility and increases the chances that they will feel comfortable doing it.  It is tightly scripted and, if the process is followed, all the steps can be covered quickly.  
• I — Immediate.  The sooner the debriefing occurs after a case, the better.  And the more likely it is to happen.
• N — Not for personal assessment.  The purpose of debriefing is to address systems issues. 
• F — Fast facilitated feedback.  The median time for debriefing is 10 minutes. Someone is assigned to be a timekeeper, to keep track of how long it is taking. The charge nurse facilitates the conversation with a focus on addressing what went well and what could be done differently next time.
• O — Opportunity to ask questions.  

Sample debrief scripting [13:30];

• The charge nurse welcomes the group and reminds everyone of their basic assumption.  “We are all here and we acknowledge that our basic assumption is we really want to do well. We’re well-trained and we want to do our best for this patient.”  The hope is that during the debriefing, people will reset and be curious as to what happened.
• Next, the charge nurse says, “We’re going to repeat the INFO mnemonic to set the expectations of what’s about to follow.” They go through the mnemonic and then ask for questions.  
• Each person is asked, “Tell me what went well for you in this case and what you would do differently next time.” 
• The debriefing concludes with:  “Are there any other questions, thoughts, comments or additions?”  After these are answered, the team is offered counseling services.  “We have counseling services available for the whole team.  The number is xxx-xxxx or contact me if you think you may need some counseling and we can get you set up for that.  Thank you for your time.”

Handling conflict or criticism that may arise during a debrief [18:35];

• If one person criticizes another member of the team, the charge nurse should use the INFO tool to bring people back into focus. An example would be to say, “I hear what you’re saying, but as you know, INFO is not about personal assessment.  It’s about team and systems assessment and improvements.  I think we need to address this issue, but let’s take that into another forum.”

The importance of establishing psychological safety [21:00];

• This is a place where people should feel free to speak and share what they’re thinking.  The group should feel that they can talk about things that are important to them, without having somebody else intervene or say something that would be upsetting.  It can help to say, “We really are curious to know what happened.  We’re not judging and if we do judge, it’s more to understand what our thoughts are about an action and to understand what happened from your perspective.”
• The INFO tool does not have an emotional component to it for two main reasons.  First, if the facilitator were to inquire about emotional issues, he/she would need an adequate amount of training and experience to be able to respond appropriately.  Second, to explore people’s emotions properly, it would take more time than most providers would have during a shift.  

Principles of a hot offload [28:15];

• Following an intense or stressful situation, it can help to employ the ‘hot offload’. This is different from a formal debriefing where all of the steps are reviewed, improvements considered, etc.
• This is a quick moment of diffusion where you go over the facts of what happened. Those involved share what they saw, heard, tasted, touched, smelled immediately after the event.
• The hot offload can reaffirm memories and also explore potentially false thought processes.
• During this process, members discuss feelings of guilt within the confines of the small unit that was involved.

Hot offload steps [32:25];

• After a bad thing happens, the team leader gets the group together to go through what they saw – the raw facts of the event.
• In the hot offload, there isn’t time for “could have, should have, would have”, because we usually don’t know if one particular action would have really made a difference.
• The team leader does a quick check in – are you OK to continue working? The team leader may have to pull someone out of work if they observe that that person is not functioning well after the event

 Ashley’s Credo [36:40];

• Work Hard, Be Respectful, Be Kind