Critical incident debriefing

"Critical incident debriefing" is the term used to describe a formal method of managing people who have been exposed to some sort of traumatic situation. In the history of the CICM Part II Exam, the trainees have been put in that position several times:

• Question 29 from the second paper of 2020
• Question 28 from the second paper of 2014
• Question 18 from the second paper of 2010.

They are all basically identical, and in these questions the candidates were asked to conduct a discussion with a junior trainee who had killed (or almost killed) somebody. 

Answers to these sorts of questions have little evidence base to support them. It is not exactly something you can run a double-blind RCT on. Most articles which discuss this topic in any depth reference an 1988 publication by Jeffrey T Mitchell, "Stress. The history, status and future of critical incident stress debriefings" - which is not available as free full text from anywhere. The next best reference is probably the 1994 update by the same author ("Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups"). The definitive reference would have to be something from the non-profit International Critical Incident Stress Foundation, who offer numerous resources. An even better resource for the time-poor trainee is a summary by Mitchell himself (the name of the article seems to be Critical Incident Stress Debriefing, but it is not very well referenced by www.firefighterveteran.com).  These resources were blended with a healthy dollop of what this autor can only describe as creating writing, and are offered below as one possible approach to answering a CICM critical incident management SAQ.

Structured management of the response to a critical incident

• Ensure the critical incident is being managed appropriately from a medical standpoint
  • Commit staff to ensure the patient is safe 
  • Ensure appropriate steps are being taken to ameliorate the risk from the critical incident (for example, if this is a line that has been accidentally inserted into a carotid artery causing a stoke - ensure that the vascular surgical team, neurology team and neurosurgical team have been consulted and have offered their opinions).
  • Delegate clinical duties so as to focus yourself on the debriefing session
• Critical incident debrief (management of the traumatised trainee)
  • Debrief session
  • Organise time off work for the trainee, if appropriate
  • Involve an impartial mentor
  • Ensure that there are support people available from the extraclinical environment (friends, family)
  • Make an offer of professional counselling
  • Give advice regarding open disclosure process and medicolegal risk
• Management of the affected patient and family
  • Clinician open disclosure 
  • Commencement of a formal open disclosure process
  • Discuss the need to refer to the coroner (if relevant)
• Management of the organisation
  • Factual and detailed documentation
  • Inform the clinical governance administrators
  • Inform the hospital medicolegal team
  • Inform the director of the department
  • Inform own medicolegal indemnity and defence organisation - as you were supposed to be supervising that trainee, and may even be responsible for the training program locally (if you happen to be the SOT).

What to expect from the affected staff

An excellent article by Laurent et al (2014) explores the reactions of notoriously Type A Intensive Care staff to their own errors. It is unfortunately not available for free. However, if one were to get a hold of it somehow, one would find that in the month following the error: 

• 53.8% described feelings of guilt and shame
• 37.5% ruminated obssessively over the error
• 23% feared for the patient
• 32.5% reported a loss of confidence
• 20% found themselves questioning their own competence at a professional level.
• In the long term, the error remained fixed in memory for many of the subjects (80%).

Rationale for the debrief session

• Critical incident debriefing is a specific, 7-phase, small group, supportive crisis intervention process. It is a form of "psychological first aid".
• It is only used in the aftermath of a significant traumatic event that has generated strong reactions in the staff, for example an unexpected cardiac arrest, or a lifethreatening error.
• It is usually conducted in small groups and its aim is a reduction of distress and a restoration of group cohesion and unit performance.
• Ideally, it should help people return to work more quickly, and it should help prevent the development of post-traumatic stress disorder.

The process of critical incident debriefing

• The debrief should happen before the affected person has had time to sleep.
• Introduce the process
• Describe the event, using whatever factual information is available
• Allow the trainee (or whatever participants) to describe their cognitive and emotional reactions to the event
• Help the trainee identify the most traumatic aspect of the event for them
• Help the trainee identify personal symptoms of distress and explore their emotional reaction to the event, assuring them that their reactions are normal.
• Educate the trainee regarding normal reactions and adaptive coping mechanisms, helping them find a "cognitive anchor". Adaptive reaction suggestions may include advice on rest, talking to one's friends and family, working with supervisors to initiate procedural changes, dealing with stress through exercise and reflection, etc. This helps the trainee transition back to a cognitive level domain, away from the emotional content of the experience.
• Clarify any ambiguities and arrange a follow-up discussion, to ensure that this debrief does not seem like a stand-alone measure but rather a part of a continuum. In a group session, this phase would end with final statemwents from the participants.

Evidence and counter-argument

According to Bledsoe  (2003), at no stage has anybody demonstrated any benefit from this process. This assesrtion comes on the back of several attempts at meta-analysis. For instance, Harris et al (2002) surveyed a large number of trauma-exposed firefighters and found that critical incident debriefing did nothing to reduce the risk of PTSD.