Implementation of the STOP 5 Debrief in the Emergency Department
Abstract
Background
The Emergency Department (ED) is often a place of high-stress or difficult cases, with very little time to process these events before returning to other duties in the department. “Hot debriefs”, or short discussions immediately following a difficult case, such as cardiac arrest, pediatric case, or high-stress situation have been shown to decrease burnout, reduce stress, and lead to key process improvements relevant to future codes. Many different styles of hot debriefs have been described, including the Take STOCK, BONE break, and TIM tool. Previous studies have compared hot vs cold debriefs, or examined standardized debrief implementation in the prehospital or ICU setting. In this project, we sought to implement the STOP 5 debrief tool immediately following cardiac arrests, pediatric codes, and other difficult cases in the ED, address physicians perceived lack of time to debrief, and improve confidence of those leading debriefs.
Methods
Nursing staff and residents were educated on the STOP 5 debrief during shift change and during educational conferences. Laminated posters were placed in the resuscitation rooms and in the “doc boxes”, areas of the ED most often occupied by attendings and residents. Standardized surveys were distributed to attendings and residents (PGY1-4) before implementation of the standardized tool and again 3 months later to gauge impressions and attitudes towards the STOP 5 debrief. Continuous variables were calculated with independent samples T-test, ordinal responses were calculated with Mann-Whitney U test, and binary responses were calculated with Fischer's exact test.
Results
A total of 50 participants completed pre-intervention surveys, and 26 participants completed post-intervention surveys. On a rating scale of 1-5, there was a significant increase in the number of physicians who felt comfortable initiating a debrief (3.28 vs 4.00, p-value = 0.036). On a rating scale of 1-5, there was no significant change in the level of confidence with regards to leading a successful debrief (3.2 vs 3.7, p-value = 0.169). The most commonly cited reasons for not having a debrief include lack of time (84%), lack of experience (30%), and “not my role” (15%), however, participants almost universally wanted more debriefs.
Conclusions
The implementation of a standardized hot debrief led to an improvement in how comfortable physicians felt initiating debriefs. There remains significant barriers to universal debriefs after appropriate cases, most notably physicians perceived lack of time and lack of confidence in leading these debriefs. Further work is needed to build a culture where hot debriefs are expected and encouraged , while further training is also needed to help ED staff feel more comfortable leading these debriefs.