Debriefing of clinical resuscitation performance: EIT 6307 TF SR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Joyce Yeung was coauthor of one of the included studies.

CoSTR Citation

Nabecker S, Cortegiani A, Breckwoldt J, de Raad T, Lennertz J, Alghaith A, Greif R, on behalf of the Resuscitation Education, Implementation and Teams Task Force.

Debriefing of clinical resuscitation performance Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2024 November 1. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of debriefing of clinical resuscitation performance conducted by the EIT Task Force members Nabecker S, Cortegiani A, Breckwoldt J, Greif R, with involvement of content experts (de Raad T, Lennertz J, Alghaith A). Evidence for adult, pediatric and neonatal literature was sought and considered by the Education, Implementation and Teams Task Force. These data were taken into account when formulating the Treatment Recommendations.

We defined debriefing of resuscitation performance as the systematic discussion of a recent resuscitation event, by participants in that event, to learn from the case or quality improvement.

We included any kind of debriefings (hot or cold debriefings, or not specified), as well as structured, unstructured, scripted and formalised debriefing in any clinical setting (adult, pediatric, neonatal cardiac arrest). We excluded resuscitation quality feedback devices or data recordings without in-person reflection or debriefing in educational settings.

Systematic Review

Publication in progress

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Healthcare providers performing resuscitation in any clinical setting

Intervention: Post-event clinical debriefing

Comparators: No debriefing

Outcomes:

Clinical

• Resuscitation skills performance (in clinical contexts – e.g. CPR quality, time to medication administration, initiation of CPR, time to defibrillation, CCF etc.) (important)

• Resuscitation knowledge (important)

Patient

• Good neurological outcome at hospital discharge / 30-days (critical)

• Survival at hospital discharge / 30-days (critical)

• Survival to hospital/event survival (critical)

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. Studies will be excluded if they are editorials, commentaries, case studies and case reports. Systematic reviews will only be used to examine included studies.

Timeframe: 2014-now (Last evidence update 2021). All languages are included as long as there is an English abstract. Last literature search: September 26, 2024.

PROSPERO Registration: PROSPERO 2024 CRD42024595033

Search Strategy: EIT 6307 Search strategy

Consensus on Science

We included 10 studies, all were non-randomized studies, as no RCT was identified. All studies were downgraded for serious risk of bias and serious to very serious inconsistency leading overall to a very low certainty evidence. The individual studies were all at serious risk of bias due to serious risk of confounding.

Six studies were in adult patients^1-6, one⁷ in paediatric and three in neonatal cardiac arrests^8-10. Interventions included post-resuscitation debriefing (not clear of timeline)¹, audiovisual feedback plus weekly 45-min post-event debriefings in the whole team², 5-min individual oral debriefing³, hot or cold debriefings based on a Bayesian hierarchical logistic regression model, adjusted for patient level and trust level confounders to explore an association between outcomes and pre-defined quality indicators⁴, weekly debriefing sessions with audiovisual feedback during cardiac arrests⁵, after training workshop with debriefing¹⁰, hospitals stratified by debriefing frequency⁶, video-assisted performance focused debriefings⁹, positive pressure ventilation refresher and performance debriefing⁸, and Interdisciplinary team debriefings within 3 weeks of a cardiac arrest⁷.

Because of this high degree of heterogeneity in the interventions, no meta-analyses could be performed.

For the critical outcome of favourable neurological outcome we identified 5 non-randomized studies^2-4,6,7 including 46.145 patients (24.751 with debriefing). We identified very low certainty evidence (downgraded for serious risk of bias, and very serious risk of inconsistency).^2-4,6,7 One study favoured hot debriefings: Couper (2020)⁴ found a 77% probability that hot debriefings increased the odds of favourable neurological outcome, with an odds ratio of 1.11 (95% credible interval 0.83-1.44) – positive effect; however they also found a 1% probability that cold debriefings increased the odds of favourable neurological outcome, with an odds ratio of 0.69 (95% credible interval 0.49-0.93) – negative effect. One study by Wolfe (2014)⁷ found that the intervention was associated with improved survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (aOR, 2.75; 95% CI, 1.01–7.5; p = 0.047). Three studies showed no effect.^2,3,6

For the critical outcome of survival to hospital discharge we identified 6 non-randomized studies^1-4,6,7 including 46.269 patients (24.820 with debriefing). We found very low certainty evidence (downgraded for serious risk of bias, and very serious risk of inconsistency).^1-4,6,7 One study favoured hot debriefings: Couper (2020)⁴ found a 67% probability that hot debriefings increased the odds of survival to hospital discharge, with an odds ratio of 1.06 (95% credible interval 0.81 - 1.37) – positive effect; but also an 11% probability that cold debriefings increased the odds of survival to hospital discharge, with an odds ratio of 0.83 (95% credible interval 0.62 - 1.11) – negative effect. One study by Wolfe (2014)⁷ found that the intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for potential confounders (age, gender, first documented rhythm, and presence of vasoactive infusions at index arrest; adjusted odds ratio [aOR], 2.5; 95% CI, 0.91–6.8; p = 0.075). Four studies showed no effect.^1-3,6

For the critical outcome of ROSC we identified 7 non-randomized studies^2-7,10 including 46.459 patients (24.904 with debriefing). We found very low certainty of evidence (downgraded for serious risk of bias, and serious inconsistency).^2-7,10One study by Couper (2020)⁴ found a 48% probability that hot debriefings increased the odds of ROSC, with an odds ratio of 0.99 (95% credible interval 0.80-1.21); and a 89% probability that cold debriefings increased the odds of ROSC, with an odds ratio of 1.15 (95% credible interval 0.90-1.43).One study Edelson (2008)⁵ showed ROSC in 59% in the intervention, and in 45% in the comparator group (p=0.03). No effect size reported. Another study by Heydarzadeh (2020)¹⁰ showed a returning duration of neonate's color to normal state: debriefing 144.8±88.6, NRP workshop 256.6±178.5, control 232.3±128.1 (p=0.004), and Apgar scores at 1, 5, and 10 min were higher in the debriefing group compared to those reported for other groups; however, these changes were not statistically significant. No effect sizes reported. Four studies showed no effect.^2,3,6,7

For the important outcome of chest compression depth we identified 3 non-randomized studies^2,3,5 including 1.773 patients (530 with debriefing). We found very low certainty of evidence (downgraded for serious risk of bias, serious risk of inconsistency, and serious risk of imprecision).^2,3,5 One study by Edelson (2008)⁵ showed a chest compression depth: 50 mm (10) in the intervention, 44 mm (10) in the comparator group (p<0.001). No effect size reported. Two studies showed no effect.^2,3

For the important outcome of chest compression rate, we identified 4 non-randomized studies ^1-3,5 including 1897 patients (599 with debriefing). We found very low certainty of evidence (downgraded for serious risk of bias, very serious risk of inconsistency, and serious risk of imprecision).^1-3,5 One study by Bleijenberg (2017)¹ showed a mean chest compression rate that was 93 (9) /min with the intervention, and 81 (13) in the comparator group (p=0.03). No effect size reported. One study by Edelson (2008)⁵ showed a chest compression rate: 105/min (10) in the intervention, 100/min (13) in the comparator group (p=0.003). No effect size reported. Two studies showed no effect.^2,3

For the important outcome of chest compression fraction, we identified 4 non-randomized studies^1-3,5 including 1.897 patients (599 with debriefing). We found very low certainty evidence (downgraded for serious risk of bias, very serious risk of inconsistency and serious risk of imprecision).^1-3,5 One study by Bleijenberg (2017)¹ showed a median chest compression fraction that was significantly better with the intervention 79% (70-85%) vs. the comparator group 86% (82-89%). No effect size reported. One study by Edelson (2008)⁵ showed a no-flow fraction: 0.13 (0.10) in the intervention vs. 0.20 (0.13) in the comparator group (p<0.001). No effect size reported. Two studies showed no effect.^3,4

For the not important outcome of adherence to resuscitation guidelines, we identified 2 studies ^8,9 including 381 patients (205 with debriefing. We found very low certainty of evidence (downgraded for serious risk of bias). ^8,9 One study by Skare (2018)⁹in the journal Acta anaesthesiologica scandinavica showed a median total Neonatal Resuscitation Performance Score (NRPE) of 89% (86, 93) in the intervention, vs. 77% (75, 81) in the comparator group (p<0.001). One study by Skare (2018)⁸ Resuscitation showed an NRPE-score of 89 (86-92) % in the intervention, vs. 77% (75-81) in the comparator group, p < 0.001.

Treatment Recommendations

We suggest to perform post-event debriefing after adult, paediatric and neonatal cardiac arrest in all settings that have the adequate resources (weak recommendation, very low certainty evidence).

Justification and Evidence to Decision Framework Highlights

Knowledge Gaps

• There is a need for randomized controlled trials on debriefing after cardiopulmonary resuscitation to avoid the inherent bias of observational studies.
• We identified insufficient evidence to address subgroup analyses, e.g. adult vs. pediatric cardiac arrest, or in-vs. out-of hospital setting, or hot vs. cold debriefing.
• We identified no study on cost-effectiveness or use of post-event debriefings in low-resource settings.
• We identified no negative effects of debriefing on the resuscitation team, however minor they might be, they should be investigated in a further review and/or further studies on the effectiveness on resuscitation debriefing.

ETD summary table: EIT 6307 Et D table debriefing

References

1. Bleijenberg E, Koster RW, de Vries H, Beesems SG: The impact of post-resuscitation feedback for paramedics on the quality of cardiopulmonary resuscitation. Resuscitation 2017; 110: 1-5

2. Couper K, Kimani PK, Abella BS, Chilwan M, Cooke MW, Davies RP, Field RA, Gao F, Quinton S, Stallard N, Woolley S, Perkins GD, Cardiopulmonary Resuscitation Quality Improvement Initiative C: The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for In-Hospital Cardiac Arrest: The Cardiopulmonary Resuscitation Quality Improvement Initiative. Crit Care Med 2015; 43: 2321-31

3. Couper K, Kimani PK, Davies RP, Baker A, Davies M, Husselbee N, Melody T, Griffiths F, Perkins GD: An evaluation of three methods of in-hospital cardiac arrest educational debriefing: The cardiopulmonary resuscitation debriefing study. Resuscitation 2016; 105: 130-7

4. Couper K, Mason AJ, Gould D, Nolan JP, Soar J, Yeung J, Harrison D, Perkins GD: The impact of resuscitation system factors on in-hospital cardiac arrest outcomes across UK hospitals: An observational study. Resuscitation 2020; 151: 166-172

5. Edelson DP, Litzinger B, Arora V, Walsh D, Kim S, Lauderdale DS, Vanden Hoek TL, Becker LB, Abella BS: Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med 2008; 168: 1063-9

6. Malik AO, Nallamothu BK, Trumpower B, Kennedy M, Krein SL, Chinnakondepalli KM, Hejjaji V, Chan PS: Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2020; 13: e006695

7. Wolfe H, Zebuhr C, Topjian AA, Nishisaki A, Niles DE, Meaney PA, Boyle L, Giordano RT, Davis D, Priestley M, Apkon M, Berg RA, Nadkarni VM, Sutton RM: Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med 2014; 42: 1688-95

8. Skare C, Boldingh AM, Kramer-Johansen J, Calisch TE, Nakstad B, Nadkarni V, Olasveengen TM, Niles DE: Video performance-debriefings and ventilation-refreshers improve quality of neonatal resuscitation. Resuscitation 2018; 132: 140-146

9. Skare C, Calisch TE, Saeter E, Rajka T, Boldingh AM, Nakstad B, Niles DE, Kramer-Johansen J, Olasveengen TM: Implementation and effectiveness of a video-based debriefing programme for neonatal resuscitation. Acta Anaesthesiol Scand 2018; 62: 394-403

10. Heydarzadeh MM, A.; Azizi, S.; Hamedi, A.; Alavi, SS.: Impact of video-recorded debriefing and neonatal resuscitation program workshops on short-term outcomes and quality of neonatal resuscitation. Iranian Journal of Neonatology 2020; 2020 Jun: 11(2)