The maternal and fetal medicine team at Sharp Grossmont Women’s Health Center, affiliated with Sharp Grossmont Hospital in La Mesa, CA, improved quality of care recently by implementing a standardized debriefing process for critical events.

Mia Taa-White, BSN, RN, and Jennifer Turney, MSN, RN, CNS, CPN, clinical leads in OB/GYN at the hospital, were part of a team that determined there was no standardized debriefing process that could help the clinical teams learn from patient experiences. They addressed the issue as part of their participation in the Clinical Scene Investigator (CSI) Academy sponsored by the American Association of Critical-Care Nurses.

The Women’s Health Center has 24 labor suites and 24 single-occupancy rooms for couplets and women’s surgical care. Physicians are in-house day and night, and there is an operating room and post-anesthesia care unit dedicated to women’s services.

Hemorrhage Incidents Reduced

They theorized that improved debriefing could help lower the incidence of a serious complication of postpartum hemorrhage resulting in a massive transfusion, defined as more than four units of blood. They developed a program with the goal of reducing the incidence below a rate of 1.5/1,000 women.

From June 2015 to June 2016, there were four cases of postpartum hemorrhage resulting in massive transfusion. In the year since implementing debriefing education and standardizing the process, there have been no events of massive transfusion and the goal to decrease the rate below 1.5 has been achieved.

The incidents avoided in that period resulted in a cost savings of $101,212. (More data and the standardized debriefing form are available online at: http://bit.ly/2AfCVDn.)

“We standardized a debriefing form that evaluates our timeliness in recognition and timeliness in responding to a critical event,” Taa-White says. “It also helps us evaluate our team dynamics. It aligned us with our journey to become a high reliability organization, heightened our awareness, and helped us create a mindset to think critically about work and performance.”

Prior to the standardized form and process, critical events were loosely defined but included anything the nurse thought required a rapid response.

Debriefing after these events was inconsistent, Turney says. “Nurses felt like they needed to weigh and discuss those events, but there was no process. Nurses would go home and think about what happened, recognize things that might have been done better or that suggested some potential for improvement, but they didn’t have any formal way to pass that on to leadership,” Turney says. “There might have been delays or supplies were missing, concrete things that could be addressed, but the information was not utilized.”

An interdepartmental team addressed the issue, with representatives from labor and delivery, OB/GYN, the surgical post-anesthesia care unit, as well as frontline nurses.

“In addition to developing a way to send this information to leadership, we wanted to be able to communicate with staff also so that we all can learn from these experiences,” Taa-White says. “We started with introducing the idea of debriefing itself — the importance of debriefing, what it means to debrief, and what would be done with the information.”

Pushback on Time, Leadership

There was some skepticism and resistance, as can be expected with any initiative, Taa-White says. Time was the biggest concern, with clinicians pushing back on the idea of a new step they would have to work into their already busy schedules. The debriefing team emphasized that the process could be quite brief, as little as five minutes.

Leading the debriefing session was another source of concern. “Everyone was shy about leading the debrief, especially with doctors involved. After a critical event, everyone is still stressed out about the situation and catching up on charting, so debriefing was the last thing they wanted to do,” Taa-White says. “The idea of leading it was even less popular, because nobody wanted to take that responsibility and be the one to criticize the team’s work. We explained that leading doesn’t mean criticizing or grading your co-workers on their performance, but rather it’s about facilitating the discussion.”

Turney notes that physician participation improved when Taa-White and another member of the debriefing team visited with OB and anesthesia leadership to explain the process and the benefits.

“It was a big step forward when we got physicians to stay after the event and discuss with the nurses what went well and what didn’t,” Turney says.

“It’s not 100% participation, but it gets better and better with each event. The physicians are starting to see that this is an opportunity for them to educate others, and also to convey any concerns they had about the equipment they needed or changes that would have helped them do their jobs better.”

Problems Revealed and Addressed

In addition to overall improvements in communication and teamwork, several specific improvements have come from the debriefings, Taa-White says. Comments from debriefings led to the refinement of the hemorrhage cart that is brought to a room during a bleeding emergency. Some necessary items were missing and new items were added.

The debriefings also revealed that the overhead speaker in a physicians’ lounge was broken, so the doctors there could not hear OB stat calls.

However, addressing those issues was not enough. The changes were communicated to the clinicians with an emphasis on how they came about directly because of the debriefings, Turney says, to reinforce the importance of the process and to validate the input from caregivers.

The debriefings also provided a way to measure the quality of critical event responses, they note. “Previously we might have thought we did pretty well, but with this process we can put our team performance on a scale of one to four and categorize it over time, looking for patterns with particular types of emergencies and any consistency in what could be improved,” Turney says.

One of the lessons from the project is that sometimes it is best to just get started rather than waiting for the perfect setup, Turney says. The debriefing team initially spent a great deal of time and effort trying to design the debriefing form, which delayed the implementation of the project, she says.

In retrospect, Turney says it might have been better to go ahead with an early version of the form and modify it as the project progressed.