Walter Eppich

Debriefing as Formative Assessment: Closing Performance Gaps in Medical Education

The authors present a four-step model of debriefing as formative assessment that blends evidence and theory from education research, the social and cognitive sciences, experience drawn from conducting over 3,000 debriefings, and teaching debriefing to approximately 1,000 clinicians worldwide. The steps are to: 1) note salient performance gaps related to predetermined objectives, 2) provide feedback describing the gap, 3) investigate the basis for the gap by exploring the frames and emotions contributing to the current performance level, and 4) help close the performance gap through discussion or targeted instruction about principles and skills relevant to performance. The authors propose that the model, designed for postsimulation debriefings, can also be applied to bedside teaching in the emergency department (ED) and other clinical settings.

Debriefing for technology-enhanced simulation: A systematic review and meta-analysis

Debriefing is a common feature of technology‐enhanced simulation (TES) education. However, evidence for its effectiveness remains unclear. We sought to characterise how debriefing is reported in the TES literature, identify debriefing features that are associated with improved outcomes, and evaluate the effectiveness of debriefing when combined with TES.

Debriefing Assessment for Simulation in Healthcare: Development and Psychometric Properties

Introduction This study examined the reliability of the scores of an assessment instrument, the Debriefing Assessment for Simulation in Healthcare (DASH), in evaluating the quality of health care simulation debriefings. The secondary objective was to evaluate whether the instrument’s scores demonstrate evidence of validity. Methods Two aspects of reliability were examined, interrater reliability and internal consistency. To assess interrater reliability, intraclass correlations were calculated for 114 simulation instructors enrolled in webinar training courses in the use of the DASH. The instructors reviewed a series of 3 standardized debriefing sessions. To assess internal consistency, Cronbach &agr; was calculated for this cohort. Finally, 1 measure of validity was examined by comparing the scores across 3 debriefings of different quality. Results Intraclass correlation coefficients for the individual elements were predominantly greater than 0.6. The overall intraclass correlation coefficient for the combined elements was 0.74. Cronbach &agr; was 0.89 across the webinar raters. There were statistically significant differences among the ratings for the 3 standardized debriefings (P < 0.001). Conclusions The DASH scores showed evidence of good reliability and preliminary evidence of validity. Additional work will be needed to assess the generalizability of the DASH based on the psychometrics of DASH data from other settings.

Emergency and critical care pediatrics: use of medical simulation for training in acute pediatric emergencies.

Purpose of the review Recent data suggest that pediatric trainees receive insufficient training to manage acute pediatric emergencies. This review addresses the use of medical simulation as a way for medical learners to acquire and maintain skills needed to manage pediatric resuscitations. Recent findings Recent work highlights the value of deliberate practice in the context of simulated medical environments to promote development of medical expertise. Several studies demonstrate the benefit of simulation-based training for improved skill acquisition in advanced life support, emergency airway management, and nontechnical skills. Work in other fields of medicine supports the integration of simulation into pediatric training programs. Summary Medical simulation holds great promise to enhance existing pediatric training curricula by increasing skills and expertise in resuscitation. Future research is needed to identify best methods of pediatric simulation-based training.

Promoting Excellence and Reflective Learning in Simulation (pearls): Development and Rationale for a Blended Approach to Health Care Simulation Debriefing

Summary Statement We describe an integrated conceptual framework for a blended approach to debriefing called PEARLS [Promoting Excellence And Reflective Learning in Simulation]. We provide a rationale for scripted debriefing and introduce a PEARLS debriefing tool designed to facilitate implementation of the new framework. The PEARLS framework integrates 3 common educational strategies used during debriefing, namely, (1) learner self-assessment, (2) facilitating focused discussion, and (3) providing information in the form of directive feedback and/or teaching. The PEARLS debriefing tool incorporates scripted language to guide the debriefing, depending on the strategy chosen. The PEARLS framework and debriefing script fill a need for many health care educators learning to facilitate debriefings in simulation-based education. The PEARLS offers a structured framework adaptable for debriefing simulations with a variety in goals, including clinical decision making, improving technical skills, teamwork training, and interprofessional collaboration.

Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing: A Multicenter Randomized Trial

IMPORTANCE Resuscitation training programs use simulation and debriefing as an educational modality with limited standardization of debriefing format and content. Our study attempted to address this issue by using a debriefing script to standardize debriefings. OBJECTIVE To determine whether use of a scripted debriefing by novice instructors and/or simulator physical realism affects knowledge and performance in simulated cardiopulmonary arrests. DESIGN Prospective, randomized, factorial study design. SETTING The study was conducted from 2008 to 2011 at 14 Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing (EXPRESS) network simulation programs. Interprofessional health care teams participated in 2 simulated cardiopulmonary arrests, before and after debriefing. PARTICIPANTS We randomized 97 participants (23 teams) to nonscripted low-realism; 93 participants (22 teams) to scripted low-realism; 103 participants (23 teams) to nonscripted high-realism; and 94 participants (22 teams) to scripted high-realism groups. INTERVENTION Participants were randomized to 1 of 4 arms: permutations of scripted vs nonscripted debriefing and high-realism vs low-realism simulators. MAIN OUTCOMES AND MEASURES Percentage difference (0%-100%) in multiple choice question (MCQ) test (individual scores), Behavioral Assessment Tool (BAT) (team leader performance), and the Clinical Performance Tool (CPT) (team performance) scores postintervention vs preintervention comparison (PPC). RESULTS There was no significant difference at baseline in nonscripted vs scripted groups for MCQ (P = .87), BAT (P = .99), and CPT (P = .95) scores. Scripted debriefing showed greater improvement in knowledge (mean [95% CI] MCQ-PPC, 5.3% [4.1%-6.5%] vs 3.6% [2.3%-4.7%]; P = .04) and team leader behavioral performance (median [interquartile range (IQR)] BAT-PPC, 16% [7.4%-28.5%] vs 8% [0.2%-31.6%]; P = .03). Their improvement in clinical performance during simulated cardiopulmonary arrests was not significantly different (median [IQR] CPT-PPC, 7.9% [4.8%-15.1%] vs 6.7% [2.8%-12.7%], P = .18). Level of physical realism of the simulator had no independent effect on these outcomes. CONCLUSIONS AND RELEVANCE The use of a standardized script by novice instructors to facilitate team debriefings improves acquisition of knowledge and team leader behavioral performance during subsequent simulated cardiopulmonary arrests. Implementation of debriefing scripts in resuscitation courses may help to improve learning outcomes and standardize delivery of debriefing, particularly for novice instructors.

Simulation-based team training in healthcare.

Introduction: Simulation-based team training (SBTT) in healthcare is gaining acceptance. Guidelines for appropriate use of SBTT exist, but the evidence base remains limited. Insights from other academic disciplines with sophisticated models of team working may point to opportunities to build on current frameworks applied to team training in healthcare. The purpose of this consensus statement is threefold: (1) to highlight current best practices in designing SBTT in healthcare and to identify gaps in current implementation; (2) to explore validated concepts and principles from relevant academic disciplines and industries; and (3) to identify potential high-yield areas for future research and development. Methods: We performed a selective review and critical synthesis of literature in healthcare simulation related to team learning as well as from other relevant disciplines such as psychology, business, and organizational behavior. We discuss appropriate use of SBTT and identify gaps in the literature. Results: Healthcare educators should apply rigorous curriculum development processes and generate learning opportunities that address the interrelated conceptual levels of team working by addressing learning needs at the level of the individual, the team, the organization, and the healthcare system. The interplay between these conceptual levels and their relative importance to team-based learning should be explored and described. Instructional design factors and contextual features that impact the effect of SBTT should be studied. Further development of validated assessment tools of team performance relevant to professional practice is a high priority and is essential to provide formative, summative, and diagnostic feedback and evaluation of SBTT. Standardized reporting of curriculum design and debriefing approaches, although difficult, would help move the field forward by allowing educators to characterize effective SBTT instruction. Conclusions: Much work is needed to establish a robust and defensible evidence base for SBTT. The complexity and expense of SBTT require that specific programs or interventions are appropriately designed, implemented, and evaluated. The healthcare sector needs to understand how team performance can be optimized through appropriate training methods. The specific role of simulation in team training needs to be more clearly articulated, and the training conditions that make SBTT in healthcare effective need to be better characterized.

Team training: implications for emergency and critical care pediatrics

Purpose of review The field of team training is quickly evolving and data are emerging to support the close relationship between effective teamwork and patient safety in medicine. This paper provides a review of the literature on team training with specific emphasis on the perspectives of emergency and critical care pediatricians. Recent findings Errors in medicine are most frequently due to an interaction of human factors like poor teamwork and poor communication rather than individual mistakes. Critical care settings and those in which patients are at the extremes of age are particularly high-risk, making emergency and critical care pediatrics a special area of concern. Team training is one approach for reducing error and enhancing patient safety. Currently, there is no single standard for team training in medicine, but multiple disciplines, including anesthesiology, emergency medicine and neonatology, have adapted key principles from other high-reliability industries such as aviation into crisis resource management training. Summary Team training holds promise to improve patient safety in pediatric emergency departments and critical care settings. We must carefully delineate the optimal instructional strategies to improve team behaviors and combine these with rigorous outcomes assessment to diagnose team problems and prescribe targeted solutions, and determine their long-term impact on patient safety.

Simulation-based crisis resource management training for pediatric critical care medicine: A review for instructors*

Objective: To review the essential elements of crisis resource management and provide a resource for instructors by describing how to use simulation-based training to teach crisis resource management principles in pediatric acute care contexts. Data Source: A MEDLINE-based literature source. Outline of Review: This review is divided into three main sections: Background, Principles of Crisis Resource Management, and Tools and Resources. The background section provides the brief history and definition of crisis resource management. The next section describes all the essential elements of crisis resource management, including leadership and followership, communication, teamwork, resource use, and situational awareness. This is followed by a review of evidence supporting the use of simulation-based crisis resource management training in health care. The last section provides the resources necessary to develop crisis resource management training using a simulation-based approach. This includes a description of how to design pediatric simulation scenarios, how to effectively debrief, and a list of potential assessment tools that instructors can use to evaluate crisis resource management performance during simulation-based training. Conclusion: Crisis resource management principles form the foundation for efficient team functioning and subsequent error reduction in high-stakes environments such as acute care pediatrics. Effective instructor training is required for those programs wishing to teach these principles using simulation-based learning. Dissemination and integration of these principles into pediatric critical care practice has the potential for a tremendous impact on patient safety and outcomes.

Evolution of the Pediatric Advanced Life Support course: Enhanced learning with a new debriefing tool and Web-based module for Pediatric Advanced Life Support instructors*

Objective: To describe the history of the Pediatric Advanced Life Support course and outline the new developments in instructor training that will impact the way debriefing is conducted during Pediatric Advanced Life Support courses. Outline: The Pediatric Advanced Life Support course, first released by the American Heart Association in 1988, has seen substantial growth and change over the past few decades. Over that time, Pediatric Advanced Life Support has become the standard for resuscitation training for pediatric healthcare providers in North America. The incorporation of high-fidelity simulation-based learning into the most recent version of Pediatric Advanced Life Support has helped to enhance the realism of scenarios and cases, but has also placed more emphasis on the importance of post scenario debriefing. We developed two new resources: an online debriefing module designed to introduce a new model of debriefing and a debriefing tool for real-time use during Pediatric Advanced Life Support courses, to enhance and standardize the quality of debriefing by Pediatric Advanced Life Support instructors. In this article, we review the history of Pediatric Advanced Life Support and Pediatric Advanced Life Support instructor training and discuss the development and implementation of the new debriefing module and debriefing tool for Pediatric Advanced Life Support instructors. Conclusion: The incorporation of the debriefing module and debriefing tool into the 2011 Pediatric Advanced Life Support instructor materials will help both new and existing Pediatric Advanced Life Support instructors develop and enhance their debriefing skills with the intention of improving the acquisition of knowledge and skills for Pediatric Advanced Life Support students.