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Effect of Briefing and Debriefing Following Neonatal Resuscitation on Patient/Clinician/Parent Outcomes (NLS #1562): Scoping Review

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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: none applicable

Task Force Scoping Review Citation

Yamada N, Stave C, Fawke J. Use of Briefing and Debriefing in Neonatal Resuscitation (NLS 1562 Briefing/Debriefing). [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, 2020 Feb 5. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review conducted by the ILCOR NLS Task Force Scoping Review team. Evidence was obtained using a structured search strategy carried out by an information specialist. Studies identified were evaluated using Covidence. This allowed independent title and abstract review by two authors (JF,NY) to see if full text review was warranted. Studies put forward by both authors were included, conflicting opinions were reviewed, discussed and resolved.

Studies identified for full text review were independently reviewed by two authors (JF,NY) to see if they matched the agreed PICOST and included if agreed by both reviewers. Conflicting opinions were reviewed, discussed and resolved. The authors agreed that psychomotor skill feedback device studies would only be included if supported by a briefing or debriefing component.

The PICOST was agreed with the ILCOR Neonatal Life Support Task Force prior to undertaking the literature search. The final scoping review was considered by the Neonatal Life Support Task Force.

Studies screened by title / abstract, those undergoing full text review and those extracted for data analysis are shown in the PRISMA diagram.

Attachments

PRISMA Flow Chart : NLS-1562-PRISMA

Scoping Review

This question has not previously been reviewed in the ILCOR 2010 or 2015 datasets.

PICOST

NLS 1562 Briefing/Debriefing

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

Population: Among health care professionals involved in the resuscitation or simulated resuscitation of a neonate (P)

Intervention: does briefing/debriefing (I)

Comparators: in comparison to no briefing/debriefing (C)

Outcomes: improve outcomes for infants, families or staff (O)?

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. Manikin studies are eligible for inclusion, animal studies are excluded. Conference abstracts and unpublished studies (e.g. trial protocols) are excluded.

Timeframe: All years and all languages are included as long as there is an English abstract. Literature search updated to January 27, 2020.

Definitions of terms used in this PICOST

Neonates: a newborn baby up to 28 days of age

Resuscitation: a newborn baby who requires support at birth to consist of a minimum of positive pressure support of breathing (PEEP or breaths given via mask, supraglottic airway device or tracheal tube).

Briefing: an act or instance of giving precise instructions or essential information (source: Merriam-Webster medical dictionary)

Debriefing: discussions of actions and thought processes after an event to promote reflective learning and improve clinical performance. Sawyer, Loren, Halamek. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? Journal of Perinatology (2016), 1-5

Simulation: an artificial representation of a real-world process to achieve educational goals through experiential learning.

Healthcare professionals: staff employed by a healthcare organization, who deliver resuscitative care (as defined above) to neonates.

Search Strategies

PUBMED:

(“infant, newborn” [mesh] OR infant* [tw] OR preterm [tw] OR preemie* [tw] OR newborn* [tw] OR neonat* [tw]) AND (“resuscitation” [mesh] OR resuscitat* [tw] OR cpr [tw]) AND (“critical reflection” [tw] OR reflection [tw] OR “post simulation” [tw] OR “pre briefing” [tw] OR prebrief* [tw] OR debrie* [tw] OR brief [tw] OR briefing [tw] OR “after action review” [tw] OR feedback [tw] OR “communication” [mesh]) AND (English [lang] OR English Abstract[ptyp])

EMBASE:

('newborn'/exp OR 'newborn' OR infant*:ti,kw,ab OR preterm:ti,kw,ab OR preemie*:ti,kw,ab OR newborn*:ti,kw,ab OR neonat*:ti,kw,ab) AND ('resuscitation'/exp OR 'resuscitation' OR resuscitat*:ti,kw,ab OR cpr:ti,kw,ab) AND ('interpersonal communication'/exp OR 'interpersonal communication' OR 'debriefing'/exp OR 'debriefing' OR 'critical reflection':ti,kw,ab OR 'reflection'/exp OR 'reflection' OR reflection:ti,kw,ab OR 'post simulation':ti,kw,ab OR 'pre briefing':ti,kw,ab OR prebrief*:ti,kw,ab OR debrie*:ti,kw,ab OR brief:ti,kw,ab OR briefing:ti,kw,ab OR 'after action review':ti,kw,ab OR feedback:ti,kw,ab) AND ([embase]/lim OR [embase classic]/lim)

WEB OF SCIENCE:

(infant* OR preterm OR preemie* OR newborn* OR neonat*) AND (resuscitat* OR cpr) AND (“critical reflection” OR reflection OR “post simulation” OR “pre briefing” OR prebrief* OR debrie* OR brief OR briefing OR “after action review” OR feedback)

COCHRANE LIBRARY:

(infant* OR preterm OR preemie* OR newborn* OR neonat*) AND (resuscitat* OR cpr) AND (communicat* OR “critical reflection” OR reflection OR “post simulation” OR “pre briefing” OR prebrief* OR debrie* OR brief OR briefing OR “after action review” OR feedback)

Inclusion and Exclusion criteria

Inclusion

Studies needed to match the PICOST

Studies of checklists were included if the checklists were specifically used for the purposes of conducting a team briefing or debriefing

Manikin or human studies were included

Studies of briefing or debriefing in the context of real or simulated neonatal resuscitation

Psychomotor skills testing was only included if it was accompanied by debriefing

Exclusions

Conference abstracts

Published protocols without a subsequent published study as a full paper

Studies that only have an abstract

Papers without an English abstract

Bundles of care where the impact of briefing / debriefing could not be separated from the rest of the bundle

Studies of briefing or debriefing in the context of pediatric or adult resuscitation

Evaluation of Included Studies

Reference

Methods

Participants

Interventions

Comparisons

Outcomes

Notes

Skare 2018 394

Prospective, pre/post interventional study. Initial phase of a multi-faceted quality improvement initiative.

Skill performance and process of care evaluation before, during and after introducing video debriefing of resuscitation events.

Evaluation used a modified Neonatal Resuscitation Evaluation Performance (NRPE) tool.

NRPE scores by single investigator but intra-rater reliability and inter-rater reliability checked by a 2ndinvestigator.

Midwives and physicians involved in resuscitation of compromised infants at a Norwegian teaching hospital in 2014.

73 resuscitation events pre- implementation were compared to 45 events post- implementation

Introduction of weekly video assisted debriefing (3rd April to 23rdJune 2014)

Followed by monthly video assisted debriefing in a post implementation period (24thJune to 24th August 2014)

NRPE scores in the pre, peri and post intervention period.

Baseline evaluations were performed 15th January to 2nd April 2014.

Pre vs post implementation

Total NRPE scores (77% vs 89%, p<0.001)

Improved preparation & adherence to the initial steps of a neonatal resuscitation algorithm (75% vs 90%, p<0.001)

Improved PPV (70% vs 100%, p<0.001)

Improved group function, communication – 88% vs 100%, p<0.001)

PPV intervention ran alongside video debriefing intervention

Sauer 2016 37397

Single centre pre- post quality improvement initiative.

Data on 548 infants representing every admission to the Palomar Rady Children’s Hospital NICU during a 35 month period (1st Jan 2010 to 30th November 2012).

It aimed to achieve:

  • Placement of a functioning pulse oximeter by two minutes after birth
  • Delayed intubation in favour of CPAP use
  • Normothermia at NICU admission
  • Use of a team prebrief, debrief and delivery room checklist to promote teamwork and communication between the obstetrician, labour and delivery room staff and the neonatal resuscitation team

High risk delivery team

(not further specified)

Described as a bundle of delivery room interventions. Individual interventions are not clearly described.

The delivery room checklist is shown in the paper and appears to be the main intervention.

Briefing / debriefing is included within the checklist.

Pre vs post intervention: Data for 249 infants prior to the intervention were compared to data for 299 born after the intervention.

Functioning pulse oximeter by 2 minutes (26% to 55%, p value unclear – see NOTES)

% intubated (14% vs 5%, p<0.001)

Surfactant use (2.8 vs 1.0%, p=0.198)

Normothermia on NICU admission (78% vs 86%, p=0.017)

% using checklist (25% to 92%, p<0.001)

Outcome data collected for RDS, BPD, death, PDA, pneumothorax, NEC, ROP, post haemorrhagic hydrocephalus (PHH), IVH, length of stay. Univariable & multivariable logistic regression done. (MV regression not for BPD, death, ROP, PHH)

No significant differences except for reduced ROP in univariable logistic regression for post intervention group (OR 0,0.696; p=0.008).

Pre & post % of infants with a functioning pulse oximeter is not clear. Pre is reported both as ‘data not collected’ and approximately 26%.

Post is variably reported as 38% (Table 2) and ‘almost 55%’ (Results text).

Authors advise caution in interpreting the reduced ROP rates.

Katheria 2013 1552

Pre/post study to evaluate the implementation of a checklist that included pre-brief and debrief components. Outcomes were measured at video resuscitation quality assurance meetings. The completed pre-brief checklist was reviewed prior to seeing each video to see if planned preparation happened. The completed debrief findings were reviewed after watching each video to see if team conclusions matched video review conclusions.

The components of the checklist were informed by crew resource management training previously undertaken by NICU staff and ongoing video reviews of neonatal resuscitations.

Neonatal faculty, neonatal fellows, pediatric residents in training, nurses, respiratory therapists.

Pre-brief:

Introduction of team members, role assignments, specific considerations, team empowered to voice concerns and to call back orders.

Equipment checklist with duty specific sub lists and required setup with the requirement to acknowledge completion.

Debrief:

Free form questions on what went well, what didn’t go well and what needed to be improved. Debrief completed soon after resuscitation with all team members involved. Members responded in order of seniority, most junior first.

QA review:

Completed checklists were reviewed with special emphasis on the debrief section at twice monthly video resuscitation quality assurance meetings.

First two years of using the delivery room checklist (March 2009 to November 2011, 260 completed checklists) were compared with the 3rd year of using the delivery room checklist (185 completed checklists).

Most common problems:

Communication (n=58)

Equipment preparation and use (n=56)

Inappropriate decisions (n=87)

Leadership (n=56)

Procedures (n=25)

During the 3rd year of use (Nov 2011 to May 2012), 185 checklists were reviewed.

Communication problems decreased from 22% to 4% (p<0.001). This finding was reported on the checklists and validated in audio & video recordings.

Non-significant changes:

  • Lack of equipment preparation & use (21% vs 23%)
  • Inappropriate decisions (33% vs 27%)
  • Leadership (21% vs 18%)
  • Procedures -sequence, timing, technique (10% vs 6%)

Unclear how often the resuscitation team members were involved in the video review meeting for each resuscitation.

Magee 2018 192

Prospective, randomised control study of Rapid Cycle Deliberate Practice (RCDP) vs. traditional simulation debriefing methods for neonatal resuscitation training.

Study occurred over 1.5 years with 3-4 interns enrolled each month.

Randomisation occurred in blocks of 4 interns to account for variations in abilities in the first year of academic training.

Pre-survey looking at confidence in neonatal resuscitation and previous experience completed.

Primary outcome was the interns’ score on the megacode assessment form (MCAF) on immediate testing.

Secondary outcomes measured at a 4 month follow-up were: confidence level in neonatal resuscitation, recall MCAF scores and time to perform critical interventions.

38 pediatric interns in a large academic training programme.

All the interns held a current NRP certification and were on a neonatology or newborn nursery rotation when enrolled.

Instructional simulation session with RCDP

Immediate simulation retest

Instructional simulation session with standard debriefing that occurred at the conclusion of the simulation scenario

Immediate simulation retest

34 interns included in the analysis. 4 were excluded due to changes in study protocol and technical issues.

Interns in the RCDP group compared to those in the simulation debriefing group:

Had higher MCAF scores than those in

(89% vs 84%, p<0.026)

Initiated PPV ventilation within 1 minute (100% vs 71%, p<0.05)

More consistently provided PPV for the appropriate duration of time before starting CC (17 vs 12, p<0.05)

Administered epinephrine earlier (152s vs 180s, p=0.039)

Self-reported confidence levels increased in both groups but were not different between the two groups.

MCAF scores and time to perform critical interventions at 4 months were not different between the two groups.

Clinical scenarios used for the instructional simulation sessions and immediate retests were the same in both arms.

Pre-written scripts, set up checklists and teaching point checklists were used for consistency in instruction. A senior neonatologist NRP instructor trained in simulation monitored for inconsistencies.

Task Force Insights

  1. Why this topic was reviewed

An ILCOR systematic review on Debriefing of Resuscitation Performance (EIT #645) considered debriefing following in hospital and out of hospital cardiac arrest in adults and children. They recommended data-driven, performance focused debriefing of rescuers acknowledging it as a weak recommendation based on very low certainty of evidence. No review has been carried out looking at the impact of briefing or debriefing on outcomes in neonatal resuscitation.

Prior systematic review of briefing/debriefing by the NLS Task Force in 2010, primarily focused on use of these techniques in the context of training rather than clinical care.

  1. Narrative summary of evidence identified

1789 studies were identified using the structured search strategy. 493 were removed as duplicates leaving 1296 studies that underwent title and abstract screening. Of these 1296 studies, 48 were identified for full text review and from this 44 were excluded. The reasons for exclusion were abstract only (15), wrong intervention (10), wrong study design (8), wrong comparator (7), study protocol (2) and wrong outcomes (2). This left 4 studies to be included in the scoping review. This is summarised in the PRISMA flow chart.

The four studies included are listed in the included studies evaluation table. One study considered video debriefing {Skare 2018 394}, one considered the use of a checklist along with video debriefing {Katheria 2013 1552}, one considered the use of a checklist with a team prebrief / debrief as the main part of a quality improvement bundle {Sauer 2016 37397} and one looked at rapid cycle deliberate practice compared to standard simulation debriefing {Magee 2018 192}.

  • Video debriefing

Skare et al installed motion activated video cameras in every neonatal resuscitation bay in a Norwegian teaching hospital. Using footage from resuscitations of compromised infants they conducted baseline skill performance and process of care assessments on 74 resuscitation events using the Neonatal Resuscitation Evaluation Performance Tool (NRPE). They implemented weekly video assisted debriefing using this footage. The debriefing was led by two experienced facilitators and focused on guideline adherence and non-technical skills. Video assisted debriefing was reviewed in departmental meeting and by the end of the study period 78% of the pediatric residents had attended.

The study period was 7 months and the team evaluations were carried out pre, peri and post implementation. The number of events evaluation was pre (74), peri (69) and post (45). Subcategories of group function / communication, preparation and initial steps, communication of heart rate, administration of oxygen, positive pressure ventilation, endotracheal intubation, chest compressions, administration of medicines and intravenous access were considered.

Pre – / post –implementation of video assisted debriefing evaluation showed that overall NRPE score improved from 77% (75, 81) to 89% (86,93) p<0.001. Improvements in were seen in the following subcategories:

  • Group function / communication 88% (75,90) to 100% (92,100) p=0.001
  • preparation and initial steps 75% (70, 80) to 90% (80, 100) p<0.001
  • positive pressure ventilation 70% (67, 75) to 100% (80, 100) p<0.001

No significant differences were reported for communication of heart rate, administration of oxygen, endotracheal intubation or administration of medicines.

Limitations of the study are the before after design and the authors acknowledge that an RCT would not have been possible. Improvements could have been due to a “Hawthorne effect” i.e. the candidates were aware they were being videoed and changed their behavior. The study was not able to blind the video reviewer as to the phase of the trial as videos had to be deleted immediately after review at their institutional review board’s request.

The authors acknowledge that whilst they have shown improvements in the process of care and adherence to guidelines the study was not powered to detect changes in clinically relevant outcomes.

  • Checklists

Two studies were identified that utilized checklists specifically for the purposes of briefing or debriefing in neonatal resuscitation.

Sauer et al implemented a quality improvement bundle that included a pre-brief, debrief and delivery room checklist. Other aspects of the quality improvement bundle were placement of a functioning pulse oximeter, normothermia on NICU admission and avoiding intubation by using CPAP. Prompts related to pulse oximeters and thermal care were included on the checklist.

This was a single centre, pre / post quality improvement study and involved all deliveries attended by the high risk delivery team at the Palomar Rady Children’s hospital over a 35 month period. The intervention was the use of a delivery room checklist that included pre-brief and debrief components. The comparison was 249 infants studied prior to introducing the checklist with 299 infants afterwards. Data was collected retrospectively from 1st January 2010 to the start of the intervention on 1st May 2011 and prospectively until 30th November 2012.

Outcomes were

  1. % using checklist
  2. % intubated
  3. Surfactant use (%)
  4. Normothermia on NICU admission (%)
  5. % with a functioning pulse oximeter by 2 minutes of age.

Results:

  • Use of prebrief, debrief and completion of the checklist increased from an initial 25% to 92% (p<0.001).
  • % of babies intubated dropped from 14.1 to 5.4% OR 0.35 (0.17, 0.66) p<0.001.
  • Surfactant use dropped from 2.8% to 1.0% OR 0.35 (0.06, 1.55) p =0.198.
  • % with normothermia on admission to NICU increased from 78.3% to 86.3% OR 1.74 (1.09, 2.8) p=0.017.
  • The % with a functioning pulse oximeter at 2 minutes was not recorded pre-intervention but increased from approximately 26% to 55% during the period the checklist was implemented.

Outcome data on RDS, death, BPD, PDA, pneumothorax, NEC, ROP, post-haemorrhagic hydrocephalus, IVH and length of stay was also collected. No differences were shown except for decrease in ROP on univariable logistic regression that the authors advised caution in interpreting.

Katheria et al conducted a pre/post study evaluating the implementation of a checklist including pre-brief and debrief components. The components of the checklist were informed by crew resource management training previously undertaken by NICU staff and ongoing video reviews of neonatal resuscitations.

Outcomes were measured at video resuscitation quality assurance meetings where the completed pre-brief checklist was reviewed, prior to seeing each video, to see if planned preparation happened. The completed debrief findings were reviewed after watching each video to see if team conclusions matched video review conclusions.

The first two years of using the delivery room checklist (March 2009 to November 2011, 260 completed checklists) were compared with the 3rd year of using the delivery room checklist (185 completed checklists).

The most common problems seen were communication (n=58), equipment preparation and use (n=56), inappropriate decisions (n=87), leadership (n=56) and procedures (n=25). Communication problems decreased from 22% to 4% (p<0.001). This finding was reported on the checklists and validated in audio & video recordings. Other changes were not statistically significant.

  • Rapid cycle deliberate practice vs. standard debriefing

Magee et al performed a prospective, randomized controlled trial to compare rapid cycle deliberate practice (RCDP) to standard simulation debriefing for teaching neonatal resuscitation on learners’ technical abilities as measured by the NRP Megacode Assessment Form (MCAF), confidence level as measured via survey, and recall in neonatal resuscitation as measured using the MCAF at a follow-up session four months later. The study was conducted at a large academic center and enrolled 38 pediatric interns. All subjects underwent a 45-minute teaching session on neonatal resuscitation. Efforts were made to ensure standardization and consistency in teaching by facilitating all sessions by the same neonatology fellow, using the same instructional simulation scenario, and using prewritten scripts, setup checklists, and teaching point checklists. A senior neonatologist NRP instructor who was trained in simulation also observed the teaching in order to monitor for inconsistencies. Outcomes were measured via 15-minute simulation test with a similar clinical scenario that occurred immediately after the instructional simulation, a post-instructional survey of confidence, and a 2nd simulation test at 4 months after the initial session.

On immediate testing, subjects in the intervention (RCDP) group had better scores on the NRP Megacode Assessment Form (MCAF), more frequently initiated positive pressure ventilation within one minute, ventilated the patient for at least 25 seconds prior to starting chest compressions, and administered epinephrine earlier. Learners in both groups reported increased confidence in neonatal resuscitation.

At the 4-month follow up test, there was no difference in MCAF scores or timing of performing critical interventions.

  1. Narrative reporting of the Task Force discussions

Given that this is a new PICOST question for the Neonatal Life Support Task Force, the Task Force elected to perform a Scoping Review in order to make an initial assessment of the available literature. Although briefing and debriefing in resuscitation has been previously reviewed by the EIT Task Force, outcomes specific to neonates or neonatal resuscitation were not included in those recommendations.

This scoping review has not identified sufficient evidence to prompt a systematic review. The evidence reviewed in this scoping review comes primarily from quality improvement studies with pre/post comparisons. There were no randomized controlled trials that compared briefing or debriefing to no briefing or debriefing. In addition, many investigators have studied briefing or debriefing in the context of bundles of interventions, but these studies were not included in this evidence review as the effects of briefing or debriefing alone were not possible to isolate in the outcomes.

We reviewed a small of number studies that included adjuncts to briefing and debriefing (e.g., the use of video and the use of checklists) as these were the only studies that compared these interventions to no briefing or debriefing rather than other interventions. The use of video-assisted debriefing may help improve the process of care and adherence to resuscitation guidelines, but evidence was not available on the effect on clinical outcomes. The use of checklists during briefings and debriefings may help improve team communication and process, but the evidence identified did not report changes in clinical outcomes and was inconsistent in the effects reported on the delivery of care.

We identified limited evidence that rapid cycle deliberate practice (RCDP) may improve short term performance in a resuscitation simulation but not confidence or retention of skills.

Briefing or debriefing may improve short-term clinical and performance outcomes for infants and staff. The effects of briefing or debriefing on long-term clinical and performance outcomes are uncertain.

Recommendations

At this time there does not appear to be enough new evidence to justify a new systematic review on the use of briefing/debriefing.

Knowledge Gaps

Although this scoping review has not identified sufficient evidence to prompt a systematic review, it highlights significant knowledge gaps in neonatal resuscitation science regarding the effects of briefing and debriefing on outcomes. Identified knowledge gaps include:

  • Effects of briefing and debriefing in isolation from other interventions.
  • Effects of briefing and debriefing on short- and long-term clinical outcomes of neonatal resuscitation.
  • Effects of rapid cycle deliberate practice in neonatal resuscitation training.

References

  1. Katheria A, Rich W, Finer N. Development of a strategic process using checklists to facilitate team preparation and improve communication during neonatal resuscitation. Resuscitation. 2013;84(11):1552-1557. doi:10.1016/j.resuscitation.2013.06.012
  1. Magee MJ, Farkouh-Karoleski C, Rosen TS. Improvement of Immediate Performance in Neonatal Resuscitation Through Rapid Cycle Deliberate Practice Training. J Grad Med Educ. 2018;10(2):192-197. doi:10.4300/JGME-D-17-00467.1
  1. Sauer CW, Boutin MA, Fatayerji AN, Proudfoot JA, Fatayerji NI, Golembeski DJ. Delivery Room Quality Improvement Project Improved Compliance with Best Practices for a Community NICU. Sci Rep. 2016;6:37397. doi:10.1038/srep37397
  1. Skåre C, Calisch TE, Saeter E, et al. Implementation and effectiveness of a video-based debriefing programme for neonatal resuscitation. Acta Anaesthesiol Scand. 2018;62(3):394-403. doi:10.1111/aas.13050

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