Background and Objective: Community hospitals often lack tertiary care support such as pediatric intensivists and anesthesiologists. Resuscitation of critically ill and injured children in community hospitals requires a well-coordinated team effort, because good team performance improves quality of care. The lack of subspecialty support makes team coordination and communication more imperative yet much more challenging. This study sought to determine if the addition of a defined focused post-mock code debriefing session improved communication skills among team members in a community pediatric emergency department.
Methods: Twenty-two volunteer members of the pediatric emergency and respiratory therapy departments at Medstar Franklin Square Medical Center took part in monthly simulated resuscitations for 3 consecutive months. After each simulation, participants answered an 18-item survey on observed communication among their team members. Members then participated in a 30-minute debriefing session in which they reflected on their own communication skills. A video taping of the resuscitation was later scored by one of the investigators by using a rubric designed by the investigators. Descriptive statistics were calculated for both the participant survey and the team communication indicator scores. Paired-sample Wilcoxon signed rank test examined the difference in the scores between each of 3 sessions.
Results: The mean scores by investigator-scored video recordings of the teams’ mock resuscitation by session showed overall team communication improved between sessions 1 and 3 for all communication areas (P = .03), with significant improvement in 4 of 9 communication areas by the third session. All team members improved communication skills as well, with the greatest improvement by the clinical multifunctional technicians.
Conclusions: Communication skills improve with the addition of focused debriefing sessions after mock codes as perceived by participants during debriefing sessions and evidenced by investigator-scored video recordings of resuscitations.
Caring for critically ill children in adult-oriented community hospitals poses unique challenges for pediatric providers given limited resources. Previous research has demonstrated that only 6% of emergency departments (EDs) in community hospitals nationally have adequate supplies to care for pediatric emergencies.1 Team-building training programs in highly complex and hazardous settings such as the ED or surgical suites are 1 method to reduce medical errors and improve patient outcomes.2 The Joint Commission’s Annual Report on Quality and Safety 2007 outlined specific areas for hospitals and health care systems to address to improve patient safety, including the use of team training and enhanced team communication.3 Team training uses a 3-pronged approach: communication, coordination, and cooperation of team members, which include physicians, nurses, and other ancillary staff.4
Residents improve learning and skill acquisition through the use of mock codes and simulations.5 Traditionally, the model was for an instructor with more knowledge and “seniority” to conduct and evaluate the performance during simulations. The education and aviation literature details the role of facilitation in training whereby the focus is no longer on the instructor, but on the learners using their experiences to analyze and draw conclusions as a team.6 The facilitator’s role is to create a safe and conducive environment for learning.
MedStar Franklin Square Medical Center implemented monthly mock codes in the Pediatric Emergency Department (PED) in 2008. After several years, staff reported that the program helped both their resuscitation skills and their confidence. However, gaps remained in the area of team communication. The goal of this study was to evaluate the effect of the addition of focused debriefing sessions after monthly mock codes. We hypothesized that debriefing sessions would enhance the acquisition of specific team communication skills needed for effective team communication by providing a safe and nonthreatening learning environment for all staff.
This study was approved by the Institutional Review Board of Medstar Health Research Institute.
MedStar Franklin Square Medical Center is a community hospital with a dedicated PED that cares for an average of 24 000 visits a year, with a mix of suburban and urban patients. The staff comprises physicians, nurses, multifunctional technician (MFT), and respiratory therapists of varying experiences and skill sets. The PED staff responds to all in-house pediatric emergencies, relying on their individual skills and experiences, as well as their collective skills, to stabilize critically ill children presenting to the hospital.
Twenty members of the PED and 2 members of the respiratory therapy department participated in the study. Each team had 11 members and was divided into 2 resuscitation teams comprising a physician team leader, a physician team member, 4 registered nurses, a MFT, and a respiratory therapist. On day 1, the 2 teams received a brief, 15-minute presentation on team communication skills necessary for effective team performance. After a 20-minute simulated mock resuscitation, participants completed an 18-item survey (Appendix A) and participated in a 30-minute debriefing session focusing on team communication skills. The teams repeated the mock scenarios 1 month later with the use of the same scenario. Finally, the same teams completed a third session a month later by using a different scenario.
The debriefing sessions followed the “Debriefing with Good Judgment”7 module recommendations. This module seeks to enable practitioners to scrutinize their subconscious perceptions and views that drive their practice, to self-correct, and hence to improve their skills. Without self-scrutiny, practitioners are inclined to ignore untrue data and continue ineffective practice habits.8 The principal investigator received one-on-one training and practice before conducting the research. During the debriefing, the principal investigator, while facilitating the participants self-discovery, expressed her recommendations as to what course of actions she would have taken during the simulation. During Debriefing with Good Judgment, the facilitator allowed participants to test the validity of her assumptions, thus allowing for a 2-way discovery.
Participants completed an 18-item self-assessment after each session based on the Team STEPPS evaluation9 (Appendix A). The sessions were videotaped. With the use of a rubric developed by the investigators based on a previously validated team performance checklist (Appendix B),10 team communication was scored by one of the investigators to avoid observer variability. Nine questions were designed to assess participants’ perception of communication by the various team members.
Mean scores were calculated for each question on both the participant survey and the team communication indicator scores. Mean scores for groups of questions (eg, prearrival, during code, and team interactions) were calculated as well. Individual question mean scores were compared by using paired-sample Wilcoxon signed rank test between session 1 and session 3. In addition to overall team scores, participants were subgrouped by role (eg, nurse, physician) and scores between the sessions were compared in a similar fashion.
Figure 1 shows the mean scores by investigator-scored video recordings of the teams’ mock resuscitation by session. Overall team communication improved between sessions 1 and 3 for all communication areas from a mean of 3.62 to 4.59 (P = .03). The 4 areas that demonstrated statistically significant improvement included the following: spoke in loud, clear voices increased from 3.67 to 4.58 (P = .02), closed the loop consistently with check backs increased from 3.25 to 4.5 (P = .004), used accurate and specific language increased from 2.5 to 4.42 (P = .001), and supported one another increased from 3.92 to 4.83 (P = .002).
Mean self-rated communication scores also demonstrated improvement over time for every team role as shown in Table 1. Overall, the MFTs demonstrated the most significant improvement in comparison with other providers with a mean increase of 0.59 points (P = .005) from session 1 to session 3. The medication nurse role demonstrated a significant improvement of 0.39 points (P = .04), and the recording nurse role showed near significant improvement as well.
The facets of MFT communication that significantly improved were in 5 of the 9 communication-oriented behaviors. Figure 2 shows the communication behaviors that improved as follows: speaking in a loud, clear voice increased from 3.59 to 4.76 (P = .002), encouraging effective teamwork increased from 4.11 to 4.82 (P = .002), shared leadership (ie, making effective suggestions to enhance resuscitation) increased from 3.9 to 4.82 (P = .02), consistently closing the loop with check backs increased from 3.85 to 4.71(P = .008), and using accurate and specific language increased from 4 to 4.82 (P = .03).
Mock codes or simulations of codes help effectively train and assess health care provider skills and competencies.7,11 Simulation has been shown to be especially helpful in learning skills required for the management of rare and critical conditions.12 With the institution of monthly mock codes in our PED, we found, based on staff feedback, that individual skills improved, our system processes streamlined and improved, yet immense gaps in our team dynamics and communication during resuscitation remained.
Our results demonstrated improvement in all facets of communication between the first and third mock code sessions by both self-report and investigator-scored video recordings. Previous research has demonstrated that postscenario debriefing provides feedback to learners with the intention of improving their performance, a type of formative assessment.13 After-event debriefing allows participants to incorporate new material into their existing memory framework providing for greater retention and, hence, recall when the information is needed again.6 The debriefing sessions after each simulation allowed the participants the opportunity to reflect on their communication skills individually and as a team, arriving at new framework in which to practice. It is likely our participants demonstrated improvement in communication skills over the 3 sessions as a result of this self-assessment.
The providers with the least education, MFTs, demonstrated the most significant improvement in communication scores. Because debriefing after mock codes provide a “safe” and “nonthreatening” environment, the less outgoing and more timid staff members are more able to voice their concerns and observations.8 Participants were able to share emotions that arose during resuscitations and, hence, confront one another in a nonaggressive environment. The unspoken hierarchy that prevented staff such as respiratory therapists or MFTs from speaking up during codes began to be dismantled. The improvement in MFT communication allows them to have greater participation and aids in creating a more effective team, which is critical to safe patient care.
This pilot study was limited by several factors. First, it was conducted at 1 location with a limited number of participants. Second, the participants were voluntary and might not represent all staff, further limiting the generalizability of the results. The limited number made it difficult to score communication for that particular role. Third, a single video camera taping the scenarios could not capture the entire team in a single frame; hence, certain nonverbal communication may have been missed. Fourth, staff absences limit the generalizability of the findings for each role. Although we anticipated staff absences, we were unable to provide enough substitutes for the physician staff and respiratory therapy staff. Unanticipated physician absence on the second scenario day lead to team disarray and impacted the communication scores, whereas respiratory therapist (RT) absence on the third day, although not as disruptive to the entire team, affected RT scores greatly for the third session. Additionally, this study lasted only 3 months. Given the relative frequency of the mock codes, it is possible that communication improved as a result of rehearsed and repetitive behavior, not necessarily the debriefings. We hope to continue to study communication over a longer time frame to assess skill retention. Finally, the results are limited by self-report of communication behavior. Although self report may not reflect actual performance, it was encouraging that the videotape-observed scores matched the self-reported scores.
Communication skills as perceived by participants and an objective observer improved with the addition of focused debriefing sessions after mock codes. Investigator-scored video recordings of resuscitations showed improvements for all facets of team communication, which was also noted by mean communication scores for all participants, particularly MFTs and medication nurses. Additionally, comments during debriefing sessions validated these findings. Improvement in team communication should lead to improvements in care of critically ill children at our institution. Other programs that use mock code simulations may want to incorporate structured debriefings into their programs. Future studies need to validate the improvements in communication and whether these results are sustainable over time.
APPENDIX A: STEPS-Pediatric ED Team – Individual Form
APPENDIX B: Team Communication Indicators Scored by Video Review
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
- emergency department
- multifunctional technician
- Pediatric Emergency Department
- respiratory therapist
- 1.↵American Academy of Pediatrics; Committee on Pediatric Emergency Medicine; American College of Emergency Physicians; Pediatric Committee; Emergency Nurses Association Pediatric Committee. Joint policy statement—guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233-1243.
- 3.↵Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2007. Available at: www.jointcommission.org/assets/1/6/2007_Annual_Report.pdf. Accessed October 1, 2011.
- 9.↵TeamSTEPPS: National Implementation. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://teamstepps.ahrq.gov. Accessed October 1, 2011.
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- Copyright © 2012 by the American Academy of Pediatrics