Hello, my name is Michael Shashadi. I am the Rapid Response Medical Director at the Hospital of the University of Pennsylvania, and I want to thank the SCCM for inviting me to speak about managing clinician stress, about uncertainty through debriefings and protocols. My disclosures include funding from NIDDK and NIGMS to study acute kidney injury. So the overview of this brief talk, I'd like to talk about debriefing and protocols during the COVID-19 surge using an example from clinical emergencies at the Hospital of the University of Pennsylvania. Then I'd like to take a look at the literature regarding debriefing and protocols and what we know about those in terms, particularly from the lens of clinician stress, and how those things may help to alleviate. And then I promise a thrilling conclusion. So first, debriefing and protocols based on our experience at HUP through the lens of clinical. So taking everyone back to the winter and spring of 2020, we had our initial COVID-19 surge at the Hospital of the University of Pennsylvania. And what this graph shows is over time from January through May of that year, the first COVID admission was on March 7th. That was a patient who went into the ICU. Only a few days after that, we had our second patient admitted. That patient was admitted to the floor. And the day after, on March 11th, we had the first response in this second COVID patient. Part of what this graph shows, just to give everyone context, is the dotted line is the COVID census at HUP. So you can see in late March and then early April, there was this dramatic rise during the surge. And then the gold line shows overall clinical emergencies. The blue line shows clinical emergencies that were called for respiratory decompensation. So during the surge, we had a pretty significant spike of respiratory decompensations. And what we found, even just in this very first rapid response, was that the clinician stress level was sky high. As soon as that rapid response was called and completed, those of us who were in the leadership received a number of phone calls, emails, etc., about any number of things that providers and nurses, respiratory therapists, pharmacists wanted to discuss to try and figure out what we could do in the context of this new disease that we were facing. So, we had a debriefing the following day. Clinical emergencies leadership, floor nursing, rapid response attending, and nurse, all of us unmasked. That didn't last very long. Some of the meeting highlights, there's a focus on restricting in-room personnel, ensuring appropriate PPE for emergency responders, dealing with the communication barriers that were created by door closure, and maintaining infection control during transport to the ICU. All of these things were brand new at the time, and we were not sure how to address them. But they ultimately formed the basis for this clinical emergencies guide. And this is one of two pages that I will show you. Our initial version did not look like this. Initially, we tried to get information just down on a PowerPoint that ended up being multiple slides, but it was cumbersome. And we knew that it would be difficult for people to follow as a protocol, as a guideline. And so, we worked with a variety of talented people at Penn, particularly people who were more tech-savvy than I was, or just good at formatting things. And we came up with this page, which summarized in tabular format, PPE and infection control. Also, according to the patient's COVID status, realizing that those who initially came in and were not suspected of having COVID might have a reassessment of that in the setting of a clinical emergency, which was one of the things that made these emergencies so stressful. That that might be the moment where people realized the patient has COVID, and if they did not have the appropriate PPE on, everybody was concerned that they were going to be exposed in some way by accident. Similarly, the management of typical respiratory interventions was altered, especially early on in the COVID surge. And so, we created a table just to try to explain to people, we know you know what to do in normal circumstances, let's adapt that. And then, similarly, we wanted to show people, look, you're going to need to use a viral filter for bagging a patient. So rather than just grabbing this from the wall, we explained where people could obtain this and then show them what it looked like. And on the other side of this, because we did have these printed out as two-sided guides, we tried to demonstrate a suggested approach to personnel both inside the room, which is at the top, and outside the room, highlighting that the door would remain closed. There were a lot of questions in the early going about what equipment would go into the room. And so, we tried to be clear about that, what would go in, what would be handed in. And then, we had a list of logistics shown here on the right-hand side about what to do in terms of PPE and what kind of roles people needed to take. This was a little bit of a difference compared to what we had previously had, where many more people, or at least a number more people, would oftentimes be in the room. We would have a surfeit of providers that would come into rooms. In this setting, in the early going, people had a lot more concern about going in, and so we needed to delineate the roles of providers who were going in to manage these emergencies. And what I'll also highlight at the bottom here is that we have a note for when this form was updated, and specifically noting to people that recommendations may evolve. Because in the early going, things were moving very fast, and we felt that we needed to alert people that different versions would be coming out. We would revise things as we would go along, and to direct people as to where they could go to obtain that information, so that they felt like they could have the most updated information. So to summarize, our experience in the early going, novel transmissible potentially lethal virus, a typically stressful event, clinical emergency, was combined with management uncertainty and personnel risk. And I characterize this as stress level that goes to 11. So you can see Nigel from the band Spinal Tap with 11. These go to 11, and there was no doubt that these clinical emergencies' stress levels were going to 11. We had a next day debrief. We identified multiple areas of uncertainty. We mapped out potential solutions, and then we developed new protocols and guidelines. We focused on the clarity of message in these. We tried to put that message in a format that would be easily accessible, and then figuring out how to disseminate these and maintaining version control were also key. So that was the experience at HOP, and I want to take a moment to take a look at the literature, and specifically asking the question, what do we know more broadly regarding the interplay between clinical uncertainty, debriefing, and protocols? Now, there's been a lot that has been written on debriefing, a lot that's been written on protocols, but here I'd like to focus on the intersection of all three of these things. What do we actually know as to what this may do or how this may affect clinician stress levels? So this is a schematic that was published in a study in the trauma literature, but references ideas of performance and arousal and anxiety that have been put forth by other authors and sort of utilized in a review of dealing with stress in the setting of trauma. So on the left-hand side, you see this graph showing an association between performance and arousal, and there's an idea or a construct that at very low arousal performance is not very good. With increasing level of arousal, you reach a peak performance, but as arousal gets very high, then you have impaired performance because of significant anxiety. And adding another component to this of cognitive anxiety, if you look on the right-hand side, that may interact with physiologic arousal, such that the effect of physiologic arousal on performance, that there may be a little bit less of a decline if there is not significant cognitive anxiety when you have more prominently increased arousal. However, if cognitive anxiety goes up, then you can have a precipitous drop in performance, particularly at higher levels of arousal. So then just add critical illness and COVID-19 with the associated lack of control, high prevalence of unknowns, and demand for quick action, and you have a recipe for decreased performance. So in this context, let's define debriefing. The American Heart Association, which recommends debriefing after cardiac arrest, notes that it is a post-event discussion between two or more individuals in which aspects of performance are analyzed with the aim of improving future performance. A hot debrief is immediate post-event, and a cold debrief, such as the one we did after our first COVID-19 rapid response, is at a later time point post-event. This is distinguished from debriefing, those of you who were watching Saturday Night Live in the mid-1980s are familiar with this being Bill Swirsky's superfans version of briefing, which is a process of reviewing and communicating pertinent facts about the resuscitation before the event. We're not going to talk about briefing. We will talk about debriefing. So in the AHA cardiac arrest guidelines, what you will note is that they are performance-focused. So performance-focused debriefing of rescuers after cardiac arrest for out-of-hospital systems, in-hospital systems, review of objective and quantitative data, and the typical outcomes focused on are things like CPR quality, return of spontaneous circulation, survival. The document notes specifically as a knowledge gap, exploration of any possible emotional side effects. So that portion of debriefing's effect is not very well explored. So what about clinician stress? Well, there are some studies that look at this. So one of the ones I really like is called STOP-5. This is from Edinburgh Emergency Medicine. It's an ED post-arrest five-minute hot debrief that you can see summarized over here. The S stands for summarize the case. T is things that went well. O is opportunities to improve. And P is points to action and responsibilities. And it is supposed to take five minutes. So you stop for five minutes. And some of the comments in that study, when they surveyed people who were involved in the rollout of STOP-5, I will quote them here, valued being given the opportunity to verbally thank each other for their hard work and to recognize that some resuscitation cases were particularly emotionally challenging. Debriefings were seen to highlight that despite being a large staff group, we prioritize team members' well-being and are supportive of one another. This was felt to improve staff morale and enhance overall team cohesion, provided a valuable pause and workload during which to address misunderstandings and to resolve conflict. And then another study of ED post-arrest hot debrief in Ireland noted that 90% of team members felt that they benefited psychologically from the process of going through these debriefings. So just a few practical pitfalls and solutions, particularly for the leader in debriefing. There are some parts of debriefing that could contribute to stress. You have to focus on shortcomings, like the main problems were. So one can take a plus-delta approach. These two components, let's list the pluses and do we have opportunity to make changes, the change being the delta portion of this. So that is one approach that one can take. Blaming language similarly in a debrief is likely to increase stress. You didn't do a good job resummarizing the case, people commenting to the leader of the event. So as the leader of the debrief, you can set the tone. This is a safe space. Let's share honestly, but focus on opportunities and not blame and encourage I statements, such as I sometimes had trouble understanding the big picture during the event. Failure to discuss concerns and opportunities. Sometimes a debrief is seen as too much back-slapping and people have concerns that they feel are not conveyed during the debrief. So one way a leader can go about addressing this is to volunteer areas for improvement, particularly what we were doing. One thing that I wish I had done a better job with can sometimes open the door for others to feel comfortable noting something that they wish were improved. And then having empathy and emphasis on the team. When we're all stepping up in an emergency, it's natural for things to get noisy, making communication more challenging for the leader. It validates that it can be difficult dealing with these circumstances. But let's talk about those challenges. And of course, because there are competing demands on time, it can be very stressful to have a long debrief. So keep it brief, but it's still important to do it. During some of this uncertainty and going back to these clinical emergencies guidelines that we put out, disseminating new clinical emergencies guidelines was a major challenge for us. We were trying to reach all stakeholders and we were competing with multiple other emerging hospital guidelines. So we used debriefs as an opportunity for education to disseminate some of these protocols. We tended to have the clinical team's attention just after an event. And the guidelines that we had may have directly addressed some of the opportunities that would be identified in the debrief. So the reception was very strong when the clinical relevance was so evident. We tried to marry the protocols with the debriefing whenever possible. Might decision fatigue be aided by protocols? I came across a study of 10 pediatric cardiologists noting 158 decisions per day across inpatient and outpatient care. That can be stressful. My own experience as a resident in treating sepsis was made less stressful by the wonderful roadmap of early goal-directed therapy. We don't need to debate the evidence there, but being able to plug into a protocol made those clinical decisions simpler. There are ups and downs of protocols. So some advantages, reducing unnecessary variability in care, quick adoption of new information to the bedside, and other such things. But there are disadvantages. You may apply these to the wrong patient. You lack individualization of care in some cases. But some of these I'll just highlight. Quick adoption of new information to the bedside and educational aids may reduce cognitive burden. And even this disadvantage may be oversimplified. Certainly the simplification of care may reduce the cognitive burden, which can be an advantage. And then similarly, if protocols can decrease errors and improve patient safety, we know that errors are associated with provider burnout, depression, PTSD, other effects. And so reducing these errors may help to reduce those effects. And lastly, I just highlight another one of our protocols. This one was developed by Jen Genestra and subsequently published. She was a fellow and now is attending at Penn. And this was trying to address a problem that came up during our COVID surge, endotracheal tube obstruction, which was something that people noted clinically ended up being a source of significant stress and required a multidisciplinary approach and then an organized protocol to get everybody on board with how we were going to manage this and make sure we were screening, checking for it, and people would be comfortable as to how to manage it. Not that people had never dealt with endotracheal tube obstruction before, but because it was coming up and oftentimes was surprising people, this information was provided and was a great aid to our clinicians in just having a roadmap to move forward and address the problem. So in summary, uncertainty is everywhere in medicine, magnified by the COVID-19 experience. Debriefing and protocols go hand-in-hand to reduce the stress of uncertainty associated with high-stakes clinical scenarios. And these tools can help to unify the clinical team. Everyone experiences clinical stress, sharing experiences highlights this, and standard clinical practice can connect providers. And last, these efforts take energy, they take strong leadership, there were many people involved in our response and debriefing and protocols to address COVID-19. I highlight two of them here, Stacey Neff and Scott Falk, who worked together with me to try to manage clinical emergencies in the early stages of COVID. And with that, I will thank you for your attention.

debriefing

protocols

clinician stress

COVID-19 pandemic

respiratory decompensation emergencies