Debriefing of Resuscitation Performance (EIT #645): Systematic Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. No Task Force members and other authors were recused from the discussion due to conflict of interest. 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: (none)

CoSTR Citation

Pflanzl-Knizacek L, Cheng A, Bray J, Duff J, Bigham B, Lockey A, Yeung J, Iwami T, Ma M, Okamoto D, Pellegrino J, Hiese M, Monsieurs K, Breckwoldt J, Gilfoyle E, Glerup Lauridsen K, Bhanji F, Finn J, Greif R. on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force.

Debriefing of Resuscitation Performance Draft Consensus on Science with Treatment Recommendations. International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2019, December 10. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of debriefing after cardiac arrest conducted by Adam Cheng and Lucas Pflanzl-Knizacek. Briefing was defined as ‘A process of reviewing and communicating pertinent facts about the resuscitation before the event’. {Kattwinkel 2010 S909} Debriefing was defined as “a discussion between two or more individuals in which aspects of performance are analyzed with the aim of improving future performance”. Inclusion criteria were health care providers, in-hospital or out-of-hospital cardiac arrest and debriefing intervention. Exclusion criteria were debriefing as part of quality intervention bundle and debriefing after simulated cardiac arrest. These data were taken into account when formulating the Treatment Recommendations.

PICOST

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

Population: Among rescuers who are caring for patients in cardiac arrest in any setting.

Intervention: Does briefing or debriefing.

Comparators: Compared with no briefing or debriefing.

Outcomes: Change survival, skill performance in actual resuscitations, improve quality of resuscitation (e.g. reduce hands-off time allowing for continuous compressions), cognitive knowledge.

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. If it is anticipated that there will be insufficient studies from which to draw a conclusion, case series may be included in the initial search. Unpublished studies (e.g. conference abstracts, trial protocols) are excluded.

Timeframe: January 1, 2014 – Sept 30, 2019, all languages are included as long as there is an English abstract.

Consensus on Science

There were no studies comparing briefing as intervention. For debriefing, data of 3 in-hospital observational before-after studies, 2 in adults {Couper 2016 130; Edelson 20081063} and 1 in paediatrics {Wolfe 20141688}, involving a total of 591 patients, and data of 1 out-of-hospital observational before-after study in adults {Bleijenberg 2017 1}, involving a total of 124 patients, was analyzed. All studies included data-driven debriefing interventions using CPR quality metrics such as chest compression depth, chest compression rate or chest compression fraction.

For the critical outcome of survival with favorable neurological outcome, we identified very low certainty of evidence (downgraded for inconsistency, indirectness and imprecision) from two observational studies {Couper 2016 130; Wolfe 20141688} including 367 patients. One study {Wolfe 20141688} demonstrated significantly increased survival with favorable neurologic outcome from the use of the intervention compared to no debriefing, while the other {Couper 2016 130} demonstrated no significant improvement from the use of the intervention compared to no debriefing. Meta-analysis demonstrates no significant effect from the use of debriefing compared to no debriefing on this outcome (RR, 1.41; 95%CI, 0.86 – 2.32; P=0.18; I²=28%).

For the critical outcome of survival to discharge, we have identified very low certainty of evidence (downgraded for indirectness and imprecision) from four observational studies {Edelson 20081063; Wolfe 2014 1688; Couper 2016 130; Bleijenberg 20171} including 715 patients. One study {Wolfe 2014 1688} reports a trend towards improved survival to hospital discharge from the use of the intervention compared to no debriefing, while three other studies {Edelson 2008 1063; Couper 2016 130; Bleijenberg 20171} demonstrated no improvement in survival to hospital discharge from the use of the intervention compared to no debriefing. Meta-analysis demonstrates a significant effect from the use of debriefing compared to no debriefing on this outcome (RR, 1.41; 95%CI, 1.03 – 1.93; P=0.03; I²=0%).

For the critical outcome of return of spontaneous circulation (ROSC), we have identified very low certainty of evidence (downgraded for inconsistency, indirectness and imprecision) from three observational studies {Edelson 2008 1063; Wolfe 2014 1688; Couper 2016 130} including 591 patients. One study {Edelson 2008 1063} reports improved ROSC from the use of the intervention compared to no debriefing, while the other 2 studies {Wolfe 2014 1688; Couper 2016 130} report no improvement in ROSC from the use of the intervention compared to no debriefing. Meta-analysis demonstrates a significant effect from the use of debriefing compared to no debriefing on this outcome (RR, 1.18; 95%CI, 1.03 – 1.44; P = 0.02; I²=0%).

For the critical outcome of chest compression (CC) depth (mean depth), we have identified very low certainty of evidence (downgraded for inconsistency and indirectness) from three observational studies {Edelson 2008 1063; Wolfe 2014 1688; Couper 2016 130) including 591 patients. One study {Edelson 2008 1063} reports improved mean CC depth from the use of the intervention compared to no debriefing and a second study {Couper 2016 130} demonstrated no improvement in mean CC depth from the use of the intervention compared to no debriefing. A third study {Wolfe 2014 1688} that reported improved compliance with CC depth targets from the use of the intervention compared to no debriefing was not included in the meta-analysis due to differing outcome measures. Meta-analysis of two studies {Edelson 2008 1063; Couper 2016, 130} demonstrates a significant effect from the use of debriefing compared to no debriefing on this outcome (mean difference = 4.00mm; 95%CI, 0.18 – 7.82; I²=79%).

For the critical outcome of chest compression rate (mean rate), we have identified very low certainty of evidence (downgraded for inconsistency and indirectness) from four observational studies {Edelson 2008 1063; Wolfe 2014 1688; Couper 2016 130; Bleijenberg 2017 1} including 715 patients. Two studies {Edelson 20081063; Bleijenberg 2017 1} report improved mean CC rate from the use of the interventions compared to no debriefing, while a third study {Couper 2016 130} demonstrated no improvement in mean CC rate from the use of the intervention compared to no debriefing. The last study {Wolfe 2014 1688} reported improved compliance with CC rate targets from the use of the intervention compared to no debriefing, but was not included in meta-analysis due to differing outcome measures. Meta-analysis of three studies {Edelson 2008 1063; Couper 2016 130; Bleijenberg 2017 1} demonstrates no significant effect from the use of the intervention compared with no debriefing on this outcome (mean difference = 5.81bpm; 95%CI, -0.08 to 11.70; I²=91%).

For the critical outcome of chest compression fraction (CCF), we have identified very-low-certainty of evidence (downgraded for risk of bias, inconsistency, indirectness and imprecision) from two observational studies {Bleijenberg 2017 1; Couper 2016 130} including 397 patients. Whereas one study {Bleijenberg 2017 1} demonstrated improved CCF from the use of debriefing compared with no debriefing, the other {Couper 2016 130} did not. Meta-analysis of these studies demonstrates no significant effect from the use of the intervention compared to no debriefing on this outcome (mean difference = 4.11%; 95CI, -1.17 to 9.39; I²=89%).

Treatment Recommendations

We suggest data-driven, performance-focused debriefing of rescuers after IHCA for both adults and children (weak recommendation, very low certainty of evidence).

We suggest data-driven, performance-focused debriefing of rescuers after OHCA in both adults and children (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

• Although the certainty of evidence is very low, our recommendations are based on the suggested positive effects of debriefing on patient and process-related outcomes for cardiac arrest.
• One limitation is that our analysis revealed high inconsistency (heterogeneity) between studies, reflecting variation in instructional design, provider type, and outcome measures.
• We have not identified any undesirable effects (i.e. emotional trauma) related to debriefing after cardiac arrest in the reviewed studies. Hence, we justify that the reported positive effects outweigh any possible undesirable effects. However, defusing emotions of rescuers after stressful or traumatic events has to be taken into account when assessing any potential risks related to debriefing.
• While the certainty of evidence is very low, the associated costs to implement debriefing are likely to be low in many institutions. However, the reviewed studies did not explore the cost effectiveness of debriefing. This is also applicable, when referring to the required resources for debriefing.
• We also consider the high likelihood that this intervention is both acceptable to stakeholders, due to potential benefits, such as improved teamwork, improved communication or identification of latent safety threats, and feasible in most institutions.

Knowledge Gaps

We identified several knowledge gaps in the published literature. These include that no studies addressed comparisons related to various specifications of debriefing, such as the format (individual feedback vs. group debriefings), the timing (hot vs. cold debriefings), use of CPR quality metrics (data-driven vs. non data-driven debriefings), or facilitation (facilitated vs. non-facilitated debriefings). Moreover, no study was adequately powered to investigate effects on patient outcome, such as return of spontaneous circulation, survival-to-discharge or favorable neurological outcome at discharge. One study was aiming at assessing the feasibility of intervention delivery rather than effectiveness {Couper 2016 130}. Thus, future study design should aim at quantitative and qualitative endpoints related to process measures, such as CPR quality metrics, and patient outcomes.

Moreover, future research questions may include training of facilitators and impact on debriefings, type of data to be included to improve effectiveness of debriefing, determination of the optimal length of debriefing, as well as exploration of any possible emotional side effects and their incidence and nature. Related to briefing, future studies may explore effects on rescuers and patients.

Attachments

Evidence-to-Decision Table: EIT-645 Debriefing

References

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.

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; 105:130-137.

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(10):1063-1069.

Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon WM, Weiner GM, Wyckoff M, Zaichkin J.Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2010; 122(suppl 3):S909–S919. doi: 10.1161/CIRCULATION AHA.110.971119.

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(7): 1688.