With the rise of behavioral health cases in its emergency department, Children’s Hospital of The King’s Daughters (CHKD) experienced an increase in the use of physical restraints among patients actively trying to harm themselves or others. Among a bundle of interventions CHKD teams have deployed to address this, clinical debriefings have been instrumental in moving the needle.
“For clinical care, it’s important to gather input from frontline team members closest to the patient — in real time or shortly after an incident — who often have the contextual experience needed to proactively co-produce solutions to prevent the next adverse event,” said Paul Mullan, MD, MPH, a pediatric emergency physician and director of research and quality improvement in the ED at CHKD in Norfolk, Virginia.
In April 2021, Mullan and a team of ED and hospital-wide colleagues launched a clinical debriefing process following behavioral health events where physical restraints were used. The implementation of the clinical debriefing program was associated with a 67% reduction in the occurrence of a repeated physical restraint episode for ED patients. Further, the total time restraints were used for all ED patients dropped from nearly 15 hours per 1,000 hours of ED care to less than three hours — a reduction of 82%.
The process
The blame-free debriefing typically lasts around five minutes, concluding with a check-in to see how everyone in attendance is doing.
- Once the patient has been stabilized, the bedside nurse, behavioral health care providers, and all other staff members involved in the incident gather for the debriefing.
- The debriefing facilitator — typically the bedside nurse — conducts the discussion using a guided script and a few questions based on the plus-delta model for clinical debriefing, where participants assess the situation by identifying things that went well or could have been better.
- The facilitator scans the debriefing form, complete with notes from the meeting, and sends it to CHKD’s behavioral health debriefing coordinator. Mullan says that having this role dedicated to reviewing and compiling information from the debriefings enables hospital leadership to address the discussed issues, identify trends, and formulate process changes moving forward.
In the two years since the program’s launch, debriefings have been conducted for more than half of the nearly 500 applicable behavioral health events at CHKD. Stressing the minimal time commitment for frontline team members to conduct the debriefings was crucial to driving staff buy-in, according to Mullan.
“People’s prior experiences with debriefings might be that they took half an hour to perform or that debriefings only occurred when the team was emotionally struggling to return to work. They needed to get past these stigmas and understand that debriefings can actually be quite brief — but high yield — meetings that focus on improving quality and teamwork,” Mullan said.
Benefits beyond the numbers
Mullan said the quality improvement benefits of the clinical debriefings go beyond the use of physical restraints. He recalled one incident where a patient became agitated and ripped a room number placard off the wall and began using it to threaten harm to the staff members; the sign was thought to be permanently affixed to the wall. Though the staff was shaken by the incident, they noted during the ensuing debrief that the other ED rooms had the same placards. The team immediately removed them all.
“Some of them may have been thinking about removing the signs, but without the debriefing they may have thought they didn’t have the consensus necessary to move forward with it alone,” Mullan said.
Mullan and his team continue to fine-tune the program, including streamlining the list of debriefing questions. The current form is down to four “high-yield” plus-delta questions from about 10 questions on the original template. As CHKD continues to track its progress in the use of physical restraints, Mullan hopes to help more children’s hospitals find similar success. He is working with other colleagues nationally on an American Academy of Pediatrics quality improvement collaborative to implement similar clinical debriefing protocols. The debriefing tool used in the study at CHKD, along with more details on other quality interventions used to decrease physical restraint rates, is published and available free online.
