Case closed. The evidence is overwhelming; clinical event debriefing (CED) is an effective way to improve multi-disciplinary team performance within Emergency Departments (EDs).

In this issue of CJEM, Rose et al. show how a CED program positively impacts individuals, teams, and systems. They add to the already convincing evidence that high performing teams are strengthened by reflecting on their performance [1]. The body of proof for CED is higher quality than many other practices in emergency medicine [2]. Why then, are we not yet routinely implementing CED programs throughout EDs across the country—just as we do sepsis pathways and STEMI protocols?

The paper by Rose et al. liberates our national EM community from spending any more time trying to “prove” that CED “works”. Instead, we now have the responsibility to focus energy on making it happen within our unique contexts. With reference to the themes described by Rose et al., we will explore four common barriers to implementation and reflect on how these can be overcome. Our current staff and future patients deserve it.

As you read, consider your own department.

Barrier one: clarity of purpose

We empathize with those in EM who remain apprehensive about CEDs. Some are skeptical of CEDs for being “soft” and “without benefit”. Yet, we see from the themes identified by Rose et al. that CEDs can have many hard impacts. These outcomes range from individual sense-making, to enhanced team relationships, to systems optimization [1]. Multi-dimensional benefits are the reason that CEDs have been adopted by high performing teams across a variety of industries [3]. Look no further than any pro sports teams, who debrief after every game. In emergency medicine, the “game” is far more serious, raising the question, how can we not regularly debrief?

The nature of CED programs and even individual conversations will sit on the spectrum from psychological first aid to quality improvement. We suggest:

  • Framing the main purpose of your CED program through a quality improvement lens

  • Acknowledging the impact CEDs have on staff wellness by fostering a sense agency in improvement processes and increased connectedness to colleagues

Barrier two: time

There are certainly competing clinical demands preventing staff from participating in CED processes. The reality, however, is that while we work with urgency and face time sensitive events, most clinical activities can wait 5 min. The time spent ensuring that individuals on the team have the necessary data set to make sense of the event, the valuable chance to improve team relationships, and the opportunity to optimize systems performance are benefits that far outweigh most potential drawbacks associated with a slight delay in attending to pending clinical tasks. Despite this reality, Rose et al. highlight that staff perceive a lack of time to be the number one barrier to engaging with CED [1].

We suggest:

  • Commit to brevity. CED conversations should take 5–10 min and those leading them must rigorously honor this commitment.

  • Pre-emptively acknowledge competing demands. The CED facilitator can acknowledge the competing demands and help staff reconcile the tension they feel from being pulled back to the busy floor.

  • Accept that perfect is the enemy of good. There will be times when it will be impossible to get the whole team together. Do not let this stop some form of CED with those available from the team.

Barrier three: skill

The work performed by Rose et al. found that staff felt that a simple tool reduced friction associated with leading and participating in debriefs. This resonates with our experience in which many staff feel quite underprepared to lead CEDs.

We suggest:

  • Adopt a simple tool. There are many available, and it does not matter which one your department chooses. Pick a tool that suits your needs and stick to it.

  • Identify and train CED champions. It is critical to support those who are best positioned to lead CEDs. Rose et al. identified charge nurses as the key group at their institution but this could vary based on context and will be impacted by local social context and hierarchies. These champions should be involved in the design, invested in through focused training, and supported in the initial CEDs they lead.

Barrier four: culture

The implementation of a CED program—the commitment to learning from everyday work—is a radical shift away from traditional safety approaches in hospitals which remain largely focused on avoiding and investigating clinical incidents. [4] Such antiquated processes are not sufficient to support safety in the complex landscape of emergency medicine. They often do the opposite. Embracing and enabling a robust CED program is a practical alternative for leaders looking to move towards a true culture of safety and excellence.

To date, many CED programs are bottom-up initiatives. They are often instigated by clinicians on the ground who recognize the desperate need for this effective individual, team, and systems level intervention in their departments. While this grassroots enthusiasm is helpful, explicit top-down support for CED programs is also needed. Such endorsement is a pre-requisite to making the three previous barriers surmountable.

We suggest:

  • Making CED a local and specialty-wide key performance indicator

  • Committing the financial resources needed to roll out debriefing including faculty development and faculty time.

  • Granting explicit permission for clinicians to engage with CED despite competing demands.

  • Consider strategically aligning the CED program with other department initiatives (i.e., the care of agitated patients, triage processes, flow, the care of elderly patients).

  • Demonstrate an ongoing commitment to staff involved in CED that any feedback has been heard and, if appropriate, actioned.

The time is now for CED to become standard practice across emergency medicine. The need exists, the evidence is conclusive, and the opportunities are numerous. Ultimately, we are left with an implementation problem. [5] Think about the purpose, time, skill, and culture in your department—what is getting in the way? We would not delay implementation of new well researched treatments for STEMI or sepsis. As an evidence-based practice, CED should be no different.