Cold Debriefs: a tool for Quality Improvement & Learningnhsscotlandevent.whitespacers.com/sites/default... · Cold Debriefs: a tool for Quality Improvement & Learning Dr E Pitt, Dr

Cold Debriefs: a tool for Quality Improvement & Learning

Dr E Pitt, Dr R Alcock, SCN G Fotheringham, Dr K Jacques – Emergency Department, Forth Valley Royal Hospital

Introduction & Aim Learning, sharing and applying lessons

is central to a system dedicated to

patient safety and improving quality of

care. There are many formats such as

Root cause analysis, Morbidity &

mortality meetings and Serious adverse

event reviews. None of these provide a means for the actual team

members involved to review a specific case they cared for in order to

create, share and act on learning specific to our setting. We have developed

a reproducible and standardised format for running Cold Debriefs

following any case in the Emergency Department (ED) that is felt worthy

of review by any member of the team. Our objective is to improve patient

outcomes and safety

using timely feedback

and reflection by the

team involved.

Methods Over 7 years we have

run more than 28 Cold

debriefs facilitated by

Emergency Medicine

Consultants & Nurses. Through an iterative process a standardised format

has been developed and agreed. The process is followed from the

moment a case is nominated by ANY member involved in any case in the

Emergency Department. This multispecialty, multidisciplinary pathway

continues until the final Learning and Action Points have been collated,

shared and acted on with all relevant hospital departments and pre-hospital

services.

Types of Cases

Results The cold debriefs have resulted in multiple technical,

non-technical and human factor changes. Examples

of these are shown in the photographs.

The benefits of cold debriefs

have been recognised and

adopted elsewhere within our

own and neighbouring hospitals.

Staff Feedback Although the primary aim is organisational learning

and quality improvement, staff feedback also indicates

valuable personal learning, reflection and peer

support.

When surveyed in 2015 80.5%

ED staff stated that they wanted

cold debriefs as part of the formal

ED feedback & support mechanism.

Some of our cold debriefs have also been initiated by Non-NHS

Emergency responders. These debriefs are now recognised as standard

practice by FVRH Emergency Department staff.

Next Steps & Limitations Cold Debriefs are time consuming to arrange & write up. It is possible

they may trigger adverse psychological response (but we are not aware of

any). In future, we would like to train more facilitators, further refine the

process of running a debrief, quality assure the completion of Action

Points and sharing of Learning Points, share this practice with other

departments that are interested in developing their own Cold Debriefs and

conduct research on impact on staff well-being.

References Kessler D et al. Debriefing in the ED after clinical events:

A practical guide. Ann Emerg Med. 2014; 10:1-9

For more information please contact elspethpitt@nhs.net

Paediatric death or critical illness: 16

SUDI, Asthma, Drowning, Non

accidental injury, Major trauma

Adult death or critical illness: 5

Fatal Burns, Sepsis, Difficult Airway, Major Trauma,

Chemical Decontamination

Obstetric: 4

Perimortem C/Section, Major Trauma, Stillbirth

Multi-casualty incidents: 3

Road traffic collisions

“This was a difficult challenge for me and

demonstrated how the Ambulance Service

and Accident & Emergency

personnel provide the utmost frontline

pre-hospital, Accident and Emergency care

in challenging environments. The cold

debrief offered closure and on reflection

highlighted the importance of sharing

information pertaining to the incident”

Conclusions • ED staff can deliver multidisciplinary/multiagency/multispecialty cold

debriefs for the hospital.

• Cold debriefs inform improvements on quality of care as well as

learning on structures and processes.

• Cold debriefs may help staff well-being but this requires further

research.