Implementation of the ‘TAKE STOCK’ Hot Debrief Tool in the ED: a quality improvement project

Hot debriefing (HoD) describes a structured team-based discussion which may be initiated following a significant event. Benefits may include improved teamwork, staff well-being and identification of learning opportunities. Existing literature indicates that while staff value HoD following significant events, it is infrequently undertaken in practice. Internationally, several frameworks for HoD have been developed, although none are widely adopted for use in the ED. A quality improvement project was conducted to introduce HoD into a single UK ED in North West England, between January and March 2019. Following stakeholder consultation, the 9-item ‘TAKE STOCK’ tool was developed. Implementation of the tool increased the number of HoD (0—2.2 HoD episodes/week). Findings from the first plan-do-study-act (PDSA) cycle are presented, which revealed the key strengths and limitations of this model. Staff perceptions of the tool were evaluated using a self-administered short questionnaire designed by the authors. Satisfaction with TAKE STOCK was assessed using 10-point numerical scales. Across respondents (n−15), average satisfaction scores exceeded 9 out of 10 concerning patient care, staff self-care, decision-making, education, teamwork and identification of equipment issues. Implementation of HoD into the ED is feasible and viewed as beneficial by staff. Implementation toolkits for TAKE STOCK have been requested by 42 additional UK hospitals and ambulance trusts, demonstrating significant interest in its use. Research is now required to formally validate HoD frameworks for use in the ED, and assess whether HoD results in sustained improvements to staff and patient outcomes.


INTRODUCTION
ED staff frequently encounter significant events. 1 Examples include cardiac arrests and traumatic, or unexpected deaths. [2][3][4] These incidents negatively affect staff, giving rise to moral injury or occupational burnout. 3 Debriefing is a process which occurs in settings such as the military, emergency services and aviation. In a range of clinical settings, including anaesthetics, obstetrics and oncology, debriefing has been demonstrated to improve staff well-being, assist learning and reduce risk of burnout. [5][6][7] Specifically, hot debrief (HoD) describes a short, team-based discussion immediately following an incident. HoD aims to address team well-being, highlight procedural issues, and generate learning opportunities. 8 9 Although psychological 'cold' debriefing (CoD) is usually deferred until a later point, HoD provides the opportunity for team members to immediately identify issues, share concerns, and highlight learning opportunities. HoD may improve perceptions of negative experiences, facilitate 'emotional venting' and promote well-being. 10 Despite the potential benefits, HoD is not common practice in healthcare. A study of Australian and New Zealand doctors and nurses 11 highlighted the perceived importance of debriefing, yet few respondents reported awareness of specific guidelines or frameworks to guide the process. A study undertaken in Canada found that debriefing occurred in less than 25% of significant events while a more recent UK study found that debriefing occurred in only 26.1% of significant events, despite 88.8% of staff declaring interest in the debriefing process. 9 12 The perceived benefits of HoD include education, improved teamwork and rapid identification of systematic errors. 13 While it is evident that barriers to debriefing exist, including time pressures, workload and cultural perceptions, 2 12 a simple tool to facilitate HoD may overcome some of these barriers.
Tools to facilitate debriefing in the clinical setting do exist. One example is the DISCERN (Debriefing In Situ Conversation after Emergent Resuscitation Now) tool, which provides a framework for the process of HoD. 14 More recently, the STOP5 tool has been proposed for implementation in the ED setting. 15 Additionally, other debriefing tools such as PEARLS (Promoting Excellence and Reflective Learning in Simulation) are helpful to facilitate CoD, 16 however, may be too time-consuming for regular use in the immediate aftermath of a significant event. Although there are differences between existing tools (table 1), all have common features, including the application of a simple structure and use of a mnemonic. Mnemonics have the advantage of being easily learnt and retained by clinicians, regardless of experience, making dissemination and subsequent standardisation straightforward. 17 Taking into account existing available tools, this project aimed to develop and introduce a HoD process unique to the needs of a single ED in the North-West of England.

Stakeholder analysis
A quality improvement project (QIP) was designed following SQUIRE (Standards for Quality Improvement Reporting Excellence) 2.0 guidelines. This was as part of an academic module undertaken by the lead author (MS), during an intercalated BSc in Urgent & Emergency Care. 18 During this programme, MS spent 9 months embedded within an ED, supported by consultant emergency physician mentors (JM and SL) and faculty including an Quality improvement report academic emergency physician (BG) and associate professor of education (PN). A personal reflection on a significant event led the lead author to identify a lack of HoD within their practice setting. In an attempt to confirm the problem locally, a retrospective audit of significant incidents was conducted through December 2018, to examine the incidence of documented debriefing. Additionally, a 10-item questionnaire exploring experiences and perceptions of HoD was distributed to a convenience sample of medical, nursing and ancillary staff (n=18) (online supplemental material 1). Analysis of the questionnaire was planned to include basic descriptive statistics and identification of key messages derived from free-text responses.
Gaining engagement from 'high interest-high power' stakeholders may help increase the likelihood of successful and sustainable change resulting from a QIP. This was accomplished within the study setting by constructing a stakeholder power grid (figure 1). 19 As a result, two senior physicians and three senior nursing staff were also consulted and individually invited to share their opinions on implementation, facilitators and barriers of a standardised HoD process. An external police representative was consulted, based on their experience of running HoD in the field. In addition, the author of a separate HoD Tool, 'STOP5', was also consulted as a subject matter expert. 15 To confirm wider agreement within the ED, findings from the stakeholder process were presented at a departmental governance meeting.

Derivation of TAKE STOCK
The structure and content of existing debrief tools were evaluated by the authors at the outset of the project. It was noted that existing tools, including STOP5, appeared to have good face validity, were user friendly and broadly relevant. However, additional items relating to equipment issues, the welfare needs of staff including the need for rest breaks, and the need for a subsequent CoD, were identified as a result of the initial stakeholder questionnaire and discussions with high interest-high power stakeholders. As these items did not explicitly feature within any existing identified HoD tool yet were deemed essential to local requirements, we identified the need for a novel HoD structure. Permission was obtained from the STOP5 team 20 to adapt the STOP5 tool into a novel HoD tool, TAKE STOCK. The 'TAKE STOCK' HoD process (box 1) follows a logical progression starting with team introductions. It progresses to explore team welfare, equipment issues/failures, incident evolution and subsequent action points. The HoD is completed alongside a record sheet, which is stored securely to facilitate subsequent CoD, ongoing audit and quality assurance (online supplemental material 2).
The 'TAKE STOCK' tool was subsequently trialled following a difficult resuscitation by the lead author to confirm usability prior to initial implementation.

Figure 1
Simplified power interest grid for identifying local stakeholders involved in the design and implementation of a new hot debrief process in the ED. Senior physicians and nursing staff were identified as 'high interest-high power' stakeholders.

Box 1 The 'TAKE STOCK' hot debrief process
1. Team gathers away from critical incident location. 2. Facilitator takes an instruction sheet and scribe is allocated to fill in record sheet. 3. Facilitator runs through 'TAKE STOCK' tool. 4. Completed record sheets placed in locked box in resus department. 5. Sheets are collected monthly and stored securely. 6. Paper copies then disposed of as per trust data protection policy. 7. If cold debrief is required, those recorded as present are individually invited by email. 8. QI lead reviews data collection forms monthly to ensure any issues are addressed or reported if necessary.

Figure 2
The TAKE STOCK hot debrief tool is an adaptation of the STOP5 model created by Edinburgh EM and the Scottish Centre for Simulation and Clinical Human Factors.

Quality improvement report Planning and outcome measures
The project was operationalised using PDSA methodology, commonly used to guide healthcare QI process. The finalised TAKE STOCK poster (figure 2) was placed in the clinical area, to prompt use following staff request or predefined significant incidents. Measured outcomes included the absolute number of HoD occurring above baseline, number of staff present during HoD, duration of HoD, and grade of the facilitator. Staff perceptions and satisfaction with TAKE STOCK was assessed using a selfreported questionnaire which was issued retrospectively by the lead author to HoD participants. This explored global satisfaction and perceptions of HoD in relation to teamwork, wellbeing, educational value, identification of equipment issues and personal well-being or skills development.
A description of key findings from the stakeholder analysis and initial PDSA cycle, conducted between January and February 2019, is presented.

Stakeholder analysis
Retrospective case note review of 21 deaths identified during December 2018 revealed that only a single debrief was documented. A total of 17/18 questionnaires were returned as part of the initial stakeholder analysis (response rate=94.4%), and included nurses (n=9, 52.9%), physicians (n=5, 29.4%) and students (n=3, 17.6%). Of these, 16 respondents (94.1%) had never participated in a HoD, despite 100% recalling at least one incident where they perceived HoD would have been useful. Of the two respondents who reported participation in HoD previously, neither reported use of a formalised process. Perceived barriers included time pressures (n=16, 94.1%), HoD not part of current culture (n=7, 41.2%), lack of staff awareness of HoD process (n=2, 11.8%), and reluctance due to perceived emotional sensitivity of events (n=2, 11.8%) (quotes 1 and 2, next). Discussions with high interest-high power stakeholders broadly confirmed these findings. In addition, senior stakeholders suggested practical recommendations for implementing and sustaining the project, such as including HoD within simulation scenarios (quote 3).
Staff members may not want to talk straight away, therefore we need to make time to debrief regularly and acknowledge the benefits Quote 1: Senior Sister [Lack of] time, this is a busy department and the next patient is always waiting Quote 2: Consultant Emergency Physician To help staff become more familiar and comfortable, [I would] recommend using the tool at the end of teaching simulation scenarios Quote 3: Consultant Emergency Physician

Initial PDSA cycle
The first PDSA cycle comprised introduction of the tool into the ED. A run chart was used to monitor progress. Over the 6-week study period, 13 HoDs took place (average 2.2/week) with an average of 9.7 staff members per debrief episode. Where start and stop times were provided (4/13, 30.7%), average duration of HoD was 8 min. The debrief facilitator included consultant physicians (8 HoDs), non-consultant physicians (4 HoDs) and the project lead, a medical student (1 HoD).
Evaluation questionnaires were distributed following the initial implementation (online supplemental material 1). A total of 15 participants responded and rated the following indicators on a 10-point ordinal scale; immediate identification of equipment issues (average rating=9.6/10), promoting a culture of teamwork (9.4/10), well-being (9.6/10) and education (9.9/10). All participants reported that HoD should become part of standard practice.
Free-text comments within the questionnaires provided deeper insight into staff perceptions of the potential effectiveness of the tool, which related to patient care, self-care, decision-making, professional education, and teamwork (quotes 4, 5 and 6, next). This could make the difference between somebody coping well at work, or leaving work because they can't cope Quote 4: Senior Nurse It gives the opportunity for questions to be answered for those who were unsure of why some decisions were made. It is useful for the welfare of all staff, not just junior members Quote 5: Consultant Emergency Physician During the first PDSA cycle, the 'study' component revealed some useful points for further improvement, including increasing the fluency of information flow during the debrief, increasing individuals' accountability for actions identified during debrief, and to encourage the delivery of constructive feedback as opposed to attribution of blame.
The data collection sheets should be altered to more clearly record who is responsible for actioning any issues found Quote 6: Consultant Emergency Physician As a result of this, the 'Act' component of the initial evaluation included restructuring of the debrief guide and data collection sheet, including a field to name individuals assigned to complete actions resulting from debrief, and a point emphasising the importance of 'no blame' culture as part of the debrief guide.
These changes were subsequently implemented on week 6 of the study (see run chart- figure 3).

DISCUSSION
The 'TAKE STOCK' HoD tool facilitates standardised and structured HoD within the ED and has increased frequency of HoD in one centre. While further evaluation is needed to confirm benefits, and reliably generalise to other settings, when taken at face value, 'TAKE STOCK' is amenable to adoption in other settings. To this end, an implementation toolkit, obtained by contacting the lead author, has been developed to support dissemination. To date, a further 42 EDs and ambulance trusts across the UK have obtained the toolkit, distributed under a Creative Commons agreement (http://www. creativecommons. org). Anecdotal feedback from early adopters is very positive, and formal feedback now planned to aid onward development.
Key lessons learnt by the authors so far that may be relevant for providers or institutions wishing to implement their own HoD processes are highlighted in box 2.

Sustainability
The TAKE STOCK HoD process continues to be used in the study centre. Since completion of the initial PDSA cycle, 17 additional debriefs have been completed, with the presenting problem of the associated clinical case documented in 11 of these (64.7%). However, it is noted that the overall frequency of HoD has decreased to about one event per month (figure 4). Proposed explanations for the reduced uptake since introduction may include new staff turnover resulting in decreased awareness of the tool and practical difficulties conducting debrief in the context of recent major changes to working practices. These include social distancing and the routine use of masks and personal protective equipment as a result of the COVID-19 pandemic. Nonetheless, TAKE STOCK continues to be used for the highest impact significant events which have included maternal death, traumatic and paediatric cardiac arrest.
To ensure TAKE STOCK continues to be utilised optimally, a subsequent PDSA cycle is planned, which will aim to recruit new process champions, determine the optimum frequency of debriefing, improve ease of documentation and address Box 2 Key lessons learnt for implementing hot debriefing (HoD) based on the experience with TAKE STOCK Do… ► …be inclusive. Shared design and ownership of the tool among all stakeholders increases acceptance and sustainability of change from the outset. ► …think beyond your tribe. Are there others (prehospital staff, receptionists, domestic staff) who would benefit from being part of the process? ► …evaluate. HoD processes should be continuously audited and improved. Don't … ► …be overly formulaic. Mnemonics and guidelines can provide useful structure, but it is sometimes desirable to deviate if the situation requires. ► …get easily disheartened. If HoD is a new concept, not all may be comfortable with implementation at the outset. 'Diffusion of innovation' theory suggests that change is likely to increase over time. ► …defer! HoD can save time and emotional energy in the longer term-make the effort after a significant event rather than deferring. Allowing a few minutes after a difficult case for HoD may help staff to more effectively focus on the next task. Quality improvement report challenges occurring because of recent adjustments to working because of COVID-19.

LIMITATIONS
Due to under-reporting within clinical records, the initial audit may have failed to capture the extent of debriefing before the design and implementation of TAKE STOCK. However, staff responses also obtained at the outset of the project confirmed the presence of a problem. Furthermore, positive staff engagement with the implementation of TAKE STOCK, and subsequent continuation of its use, indicates that an important need has been addressed. As this report only concerns the initial PDSA cycle, current evaluation data are limited which means that conclusions must be considered cautiously. Ensuring longer term sustainability is a critically important aspect of quality improvement yet is frequently overlooked. 21 In this case, the project was led by a student and implementation of subsequent PDSA cycles was hindered by the transient nature of their placement. Quality improvement work in the ED may frequently be initiated by staff on time-limited attachments, and in such cases handover and delegation of onward work should be considered an essential component of the sustainability plan from the outset. Nonetheless, a subsequent PDSA cycle is now planned, and it is acknowledged that the tool may further evolve to meet the needs of clinicians. To gain in-depth views of stakeholders, some qualitative data were collected in the form of free-text responses within questionnaires. However, the limited nature of these data precluded a formal thematic analysis. As already identified, multiple HoD tools do exist. Scientific evidence underpinning the use of HoD tools, including confirmation of desirable and beneficial characteristics, is currently lacking, and in many cases is restricted to anecdotal data. Although it is appreciated that providers may wish to adapt and produce their own bespoke HoD solutions, formal comparative analysis of existing tools would be beneficial to assess usability and face validity among end-users, as well as confirm benefits for staff well-being, patient safety and clinical outcomes.

CONCLUSION
Introduction of HoD in the ED may enhance staff well-being, improve teamwork and generate increased learning from incidents. Each of these factors has the potential to improve patient care. The introduction of standardised approaches such as TAKE STOCK may empower providers to initiate debriefing, helping ensure that HoD becomes embedded in practice.
Correction notice This article has been corrected since its publication. The authors wish to make it clear that the Take Stock tool was adapted from STOP5. The methods have been updated to clearly reflect this.