Since the modern cardiopulmonary resuscitation (CPR) was first described by van Kouwenhoven et al (1) in 1960, many adults and children have undergone this potentially life-saving procedure. Pediatric cardiac arrest, even in-hospital, is a critical and often strong emotional event associated with a high mortality ratio. A recent multicenter study shows that the mortality among children after in-hospital cardiac arrest is around 61%. As the majority of survivors (89%) may show a favorable neurological outcome, it seems of great importance to maximize the quality of our CPR procedures (2).
An optimal technical performance of a CPR procedure seems of major importance (3). But it has also been shown that the outcome of cardiac arrest at the PICU, independent of the underlying cause of cardiac arrest, relies on many other variables. Among these are experience of nursing staff, arrest procedures at weekends, and PICU unit–specific factors (4). As a cardiac arrest procedure is mainly a team effort, the quality of the CPR team performance might also be an important factor. Since high-quality CPR team performance does not come easy, team performance and human factors need to be addressed in this field.
In this issue of Critical Care Medicine, Wolfe et al (5) describe the results of their study concerning the effect of a structured, quantitative, audiovisual, and interdisciplinary debriefing of CPR procedures on survival and quality. This single-center prospective interventional study at a high-volume mixed PICU was aimed at cardiac arrest procedures at the PICU. The primary outcome variable was survival to discharge; secondary outcome variables included neurological outcome and resuscitation quality. The latter was defined as a chest compression depth ≥38 mm, rate ≥100/min, ≤10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch in children older than 8 years. Chest compression quality was recorded using a chest compression feedback device connected to a monitor/defibrillator device.
In total, the authors collected data from 119 CPR procedures. The results of these CPR procedures after implementation of the debriefing intervention were compared with a historical control group. In terms of outcome, the authors found a trend toward an increase in survival to hospital discharge and a significant increase in survival with favorable neurological outcome. Also the quality of the CPR procedure improved, as CPR epochs for patients older than 8 years after intervention were 5.6 times more likely to meet standards of excellent CPR.
It is hard to ascertain whether and how the introduction of nontechnical tools like a debriefing will increase the level of team performance resulting in improved patient outcome. Therefore, the authors are to be congratulated for these results. However, this study also carries some weak points. First, only qualitative data from children older than 8 years could be analyzed due to technical constraints of the feedback devices that are only useful in older children. Also the use of historical controls is always a disadvantage. On the other hand, these types of interventions can probably not be studied in a randomized controlled fashion since they concern the performance and awareness of all professionals involved. As the authors also correctly state, the study was underpowered to detect a difference in survival to discharge leading to only a trend in improved survival (p = 0.054).
Wolfe et al (5) performed their intervention by introducing interdisciplinary (including physicians and nurses) debriefings that were conducted within 3 weeks of every CPR event. It is not clear whether participation was mandatory, but the debriefing was not limited to the participators in the CPR procedure. Others have also identified the usefulness of a structured debriefing, not only after CPR but also in other critical ICU situations as well (6, 7).
Why is debriefing such a powerful tool? It is a structured way to identify lessons learned shortly after a procedure with the aim to improve future performance on an individual and team level. An effective debriefing setting has several characteristics. First, debriefings have to be a predictable, nonfacultative part of every critical operational process. This lowers the emotional threshold to share experiences and helps standardize operational flow (Standard Operating Procedure). Second, debriefings should have a standard content to maximize efficiency. An example of a standard debriefing could be plan versus outcome, lessons learned, and questions. Third, for debriefings to become effective, a safe, nonpunitive setting is essential, as it allows also sensitive observations and emotions to be shared. The bigger the audience, the more challenging this becomes. Therefore, limiting participation in the initial debriefing to the operational team that performed the procedure seems preferable, as is done in the military aviation environment.
As the authors mention, generalized debriefings (participation not limited to the operational team) may be an effective way of education too as others, besides the team involved may learn firsthand from a colleague’s experience. But large clinical meetings do not automatically result in optimal debriefing settings as strong professional opinions in a blaming environment may impact the information volunteered.
Although the debriefing has the potential to be a strong instrument in improving team performance, it relies on a nonpunitive, safe professional climate to be most effective. Therefore, it seems only logical to view the introduction of structured debriefings as part of a bigger intervention aimed at improving safety climate. In aviation, this “climate intervention” called Crew Resource Management (CRM) was implemented successfully many decades ago and became today’s operational standard. Only recently, this approach has been introduced into clinical medicine (8). CRM is based on the premises that humans make errors and that these errors can be prevented or the effects mitigated (9). Important domains of CRM are, among others, situational awareness, feedback, leadership, and closed-loop communication. It requires several interventions of which debriefing is one. Others include briefing, structured handovers, and efficient rules for feedback in communication. Indeed CRM can be useful within CPR procedures (10).
We believe that Wolfe et al (5) have shown us that a straightforward intervention like a structured debriefing makes a difference in patient outcome. However, all aspects of CRM should be studied and, when shown to be effective, implemented in all critical care departments. Clinical outcome after cardiac arrest is not only determined by technical and procedural proficiency of the CPR code team but also by the nontechnical performance of the professionals involved. Therefore, it is time that we should appreciate the human factor.
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