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Picture this: Fifteen minutes into a Code Blue, the patient your team is trying to resuscitate is pronounced dead. The code stops, and a wave of fatigue hits you as the adrenaline and intensity of the event start to recede. Just moments later, you’re called to return to the patient you were helping before the code began. There’s no chance to pause, process the event, discuss with the team, or review any data. You feel confident in the team’s overall response and execution, but you’re still left with nagging questions and lingering doubt: Should I have done something differently? Would it have changed the outcome?

Unfortunately, this is a scenario that’s all too common for clinicians today. The American Heart Association (AHA) has long recommended and emphasized the benefits of regular post-resuscitation debriefing, or “hot debriefs.” But with time constraints and unrelenting clinical demands as top barriers, many Code Blue teams struggle to implement them consistently. In one survey of hospitals in the AHA’s Get With The Guidelines®-Resuscitation registry, only 14% said that hot debriefs occurred frequently after in-hospital cardiac arrest (IHCA) events — and nearly half reported that they occurred rarely or never.1

Percentage of Hospitals Reporting Frequency of Code Blue Debriefs1

14

HOLD DEBRIEFS FREQUENTLY
(81 - 100% of IHCAs)

42

HOLD DEBRIEFS OCCASIONALLY
(21 - 80% of IHCAs)

43.5

HOLD DEBRIEFS
RARELY OR NEVER
(0 - 20% of IHCAs)

So how can hospitals make hot debriefs stick — and ensure that they’re effective? In this article, we’ll start by covering the basics of a hot debrief: what it is, and why it’s important to conduct one after a Code Blue. Then we’ll share practical tips for implementing an effective hot debriefing program at your hospital.

hot debrief: the basics

 

What it is: During a hot debrief, the Code Blue team convenes immediately after the event to review the details of the case and identify areas for improvement.

How is it different from a cold debrief? Cold debriefs happen at less frequent, scheduled intervals (monthly, quarterly) and typically include aggregate data from recent cases. A hot debrief occurs immediately after an event and focuses only on the code that just took place — while the details are still fresh.

 

Why conduct a hot debrief?

Since cold debriefs offer the advantage of more detailed data and analysis, it can be tempting to skip the hot debrief altogether. But hospitals that do miss out on some important benefits:

  • Feedback loop: It can be difficult to reconvene the same code team at a later date. This means that the hot debrief is the best opportunity to discuss less quantifiable (but equally important) aspects of the code, such as role clarity and how well the team worked together.
  • Knowledge and retention: Since the events are still fresh, the details discussed at a hot debrief can be very powerful. Responders are far more likely to retain the information shared and apply it to the next code.
  • Reflection and processing: Code Blues can be stressful and emotionally charged for any resuscitation response team. Allowing even a brief amount of time to process the event as a group can help reduce feelings of stress, disenchantment, and burnout.2
  • Performance and outcomes: Studies show that debriefing programs have the potential to improve factors like cardiopulmonary resuscitation (CPR) quality, return of spontaneous circulation, and neurologic outcomes.3,4

While it’s helpful to know (and regularly communicate) the why behind the hot debrief to get support for the program, it’s the how that many hospitals find challenging. In the next section, we’ll take a closer look at 3 tips hospitals can use to implement — and maintain — a successful hot debriefing program.

1. Make it a habit

Consistency is key when it comes to hot debriefs. Once debriefing becomes a regular part of the routine, hospitals are far more likely to start experiencing the benefits discussed above. Practically speaking, that’s much easier said than done. Here are some tips to make hot debriefs a habit:

  • Designate a leader. Code teams tend to disperse quickly after the event ends. But that’s less likely to happen if someone is responsible for gathering the group and facilitating a quick discussion. Depending on your hospital and the makeup of your resuscitation response team, the person in charge of the debrief might be the scribe, the code leader, or another team member.
  • Use a standardized format. Give staff the right tools and a standard format to use, and it will be easier to follow through. This can be as simple as a checklist or script of questions to run through during the hot debrief. For example, the AHA offers several hot debriefing forms for your hospital to model or use. And some electronic documentation tools, such as Nuvara’s CoDirectorTM resuscitation software, auto-generate a hot debriefing report for you after each event. These reports not only provide the objective data that teams rely on to improve, but also allow space for the group to rate itself on aspects like teamwork, communication, and leadership.
  • Keep sessions short and focused. Whatever tool you choose, following a standardized structure and format can also keep the session brief and to the point.4 Limiting the discussion to 5-10 minutes will help alleviate concerns about timing and workload that prevent hot debriefs from happening consistently — or at all.5

What to Include in a Hot Debrief

The exact structure of the debrief will vary depending on your hospital, but often looks something like this4,6,7:

  1. Introduction: Thank everyone for attending and state the goals of the debrief.
  2. Reactions: Have participants briefly reflect on their feelings and reactions to the code.
  3. Overview: Provide a quick clinical summary of the code. This is a good opportunity to include objective data on CPR quality and adherence to Advanced Cardiac Life Support (ACLS) algorithms.
  4. Plus/Delta analysis: Ask the group — What went well? What would you have done differently?
  5. Summary: Quickly review the main discussion points and key takeaways before the group disperses.

 

2. Set the tone

Creating the right environment is essential to the success and productivity of the debrief.7,8 This is especially true in the immediate aftermath of a high-stakes event, when adrenaline and emotions are still running high.

  • To do this, start each debrief by reminding the group of the purpose: for education, quality improvement, and event processing — not for punitive reasons or blame. Thank everyone for their participation, encourage input, and reinforce the confidentiality of the discussion. Don’t skip this step, even as hot debriefs become more routine at your hospital. If debriefing gets a reputation as a blame session, clinicians are understandably less likely to stick around for it — or to absorb and use the information that’s shared.
  • Then maintain this tone throughout. Clinicians are highly skilled and capable of performing at their best under pressure, so if the code didn’t go according to plan, look for the underlying gaps in the process that led to it. Are there knowledge areas that deserve more emphasis in mock Code Blues and other trainings? Did the code team lose valuable time due to missing or disorganized equipment and supplies? These are the kinds of larger themes you’ll want to take back to key stakeholders as well. Depending on your hospital, that might include the Code Blue Committee or a resuscitation champion.
  • Lastly, always take a minute to discuss what went right during the code. It’s easy to focus only on the areas that need improvement, but clinicians may walk away from the event feeling burned out, demoralized, and questioning whether their efforts mattered. Did the team communicate clearly and work well together? Did they effectively minimize pauses during CPR? Highlighting the team’s strengths is essential for both morale and future performance.

3. Use data

If clinicians consistently receive feedback after every Code Blue they participate in, their performance is likely to improve over time. Plus, clinicians will be more motivated to attend hot debriefs if they regularly receive useful, actionable information during them. But here’s the catch: that feedback needs to be accurate and data driven, and hospitals need to be able to access the data quickly to use it in a hot debrief.

This may sound impossible, especially since most hospitals are still documenting Code Blues with pen and paper. Fortunately, it’s not: Including data in the hot debrief is not only possible — it’s essential. Here’s how:

  • Use the data available to you now: CPR feedback devices, end-tidal carbon dioxide readings, defibrillator transcripts, and records of medication administration times are all potentially rich sources of information.3,8,9 Even if you don’t have access to all the data immediately after the code, use what’s available now.
  • Invest in electronic documentation tools: Electronic documentation not only captures data more accurately during the code — it also makes it easier to extract and interpret key data points afterward. As more hospitals adopt electronic documentation tools, data and insights will be readily available after the event to discuss during the hot debrief. For example, Nuvara’s CoDirector debriefing report provides instant feedback to responders on multiple quality indicators:
    • Chest compression fraction
    • Duration of CPR pauses
    • Time to first defibrillation for shockable rhythms
    • Time to first and subsequent epinephrine administrations for asystole and pulseless electrical activity
    • Method used to confirm airway placement

Data-driven debriefing at your fingertips

Ready to take your Code Blue hot debrief to the next level? With Nuvara’s CoDirector Resuscitation Software, your code team has access to automated data and performance insights immediately after the event.

References

  1. Malik, A.O., Nallamothu, B.K., Trumpower, B., et al. (2020). Association between hospital debriefing practices with adherence to resuscitation process measures and outcomes for in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes. 13(11). https://doi.org/10.1161/CIRCOUTCOMES.120.006695
  2. Mullangi S., Bhandari R., Thanaporn P., et al. (2020). Perceptions of resuscitation care among in-hospital cardiac arrest responders: a qualitative analysis. BMC Health Services Research, 20(145). https://doi.org/10.1186/s12913-020-4990-4
  3. Institute of Medicine. (2015). Strategies to improve cardiac arrest survival: a time to act. Washington, DC: The National Academies Press.
  4. Kessler D.O., Cheng, A., & Mullan, P.C. (2015). Debriefing in the emergency department after clinical events: a practical guide. Annals of Emergency Medicine, 65(6): 690-698. https://doi.org/1016/j.annemergmed.2014.10.019
  5. Sawyer T., Loren D., & Halamek, L.P. (2016). Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol, 36(6): 415-9. https://doi.org/10.1038/jp.2016.42
  6. Welch-Horan T.B., Lemke, D.S., Bastero, P., et al. (2021). Feedback, reflection, and team learning for COVID-19: development of a novel clinical event debriefing tool. BMJ Simul Technol Enhanc Learn, 7(1):54–57.
  7. Eppich W., & Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc, 10(2):106-15.
  8. Cheng, A., Nadkarni V.M., Mancini, M., et. al. (2018). Resuscitation education science: educational strategies to improve outcomes from cardiac arrest. Circulation, 138, e82-e122.
  9. Part 7: Systems of Care. 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Available at: Part 7: Systems of Care | American Heart Association CPR & First Aid
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