Abstract
Problem: The Cardiac Surgery Intensive Care Unit (CSICU) at an academic medical center is experiencing an increase in critical events. The 2022 Safe and Reliable Healthcare Safety, Communication, Operational Reliability, and Engagement (SCORE) Survey revealed that this unit scored in the lowest percentile for burnout climate and over seventy percent of the nursing staff left in a span of six months. The staff feels this has resulted in a lack of guidance and a chaotic environment. Incident reports have also shown an increase in near-miss events.
Purpose: The purpose of this quality improvement (QI) project is to utilize the institution’s critical event debrief tool to implement a practice change to improve teamwork and patient safety.
Methods: Project procedures that took place in the week preceding implementation included education for twenty-six charge nurses on the correct utilization of the institution’s validated critical event debrief tool, adopted from the Immediate, Not for personal assessment, Fast facilitated feedback, Opportunity to ask questions (INFO) tool. During implementation, charge nurses serve as facilitators and conduct post critical event debriefs with multidisciplinary team members using the debrief tool after qualifying events. Qualifying criteria for a debrief put in place by the institution includes cardiac arrest, difficult airway response, extracorporeal membrane oxygenation (ECMO) team activation, emergent intubation, self extubation, massive transfusion event activation, chemical code, and patient falls. Weekly, completion of the debrief tool is audited by the QI team lead using the audit tool, beginning after week one of education throughout the 15-week period. Additionally, the stakeholder team analyzes debrief feedback for QI themes for teamwork and safety through the weekly audits of the tool.
Preliminary Results and Conclusions: In the thirty days prior to implementation, there were fifty-eight eligible events, twenty of which were rapid response utilizations or cardiac arrests. Of these events, zero debriefs were documented. Currently, the project is three days into implementation. There have been no eligible events for debrief thus far. However, ninety two percent of the charge nurses were educated on the facilitation of debriefs. Structural goals were one hundred percent met in placement of quick response (QR) codes at all nurses’ stations and huddle rooms on the unit. Baseline data and goals projected for the implementation thus far suggest that there is a large opportunity for improvement in adherence to debriefing critical events. Based on the existing evidence, there is a predicted positive association between this implementation and an increase in teamwork and patient safety. The study is ongoing and will be completed December 2023.
Notes
Presenter notes available in attached slide deck.
Reference list included in attached slide deck.
Sigma Membership
Pi at-Large
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Quality Improvement
Research Approach
Other
Keywords:
Intensive Care Units, Cardiac Surgery, Surgical Intensive Care, Debrief Tool, Teams in the Workplace, Teamwork, Critical Incident Stress
Recommended Citation
Law, Kendall Elizabeth; Wanzer, Megan; and Costa, Linda, "Implementation of Event Debriefing to Improve Teamwork and Safety in Cardiac Surgery" (2026). Creating Healthy Work Environments (CHWE). 96.
https://www.sigmarepository.org/chwe/2024/presentations_2024/96
Conference Name
Creating Healthy Work Environments
Conference Host
Sigma Theta Tau International
Conference Location
Washington, DC, USA
Conference Year
2024
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-03-03
Implementation of Event Debriefing to Improve Teamwork and Safety in Cardiac Surgery
Washington, DC, USA
Problem: The Cardiac Surgery Intensive Care Unit (CSICU) at an academic medical center is experiencing an increase in critical events. The 2022 Safe and Reliable Healthcare Safety, Communication, Operational Reliability, and Engagement (SCORE) Survey revealed that this unit scored in the lowest percentile for burnout climate and over seventy percent of the nursing staff left in a span of six months. The staff feels this has resulted in a lack of guidance and a chaotic environment. Incident reports have also shown an increase in near-miss events.
Purpose: The purpose of this quality improvement (QI) project is to utilize the institution’s critical event debrief tool to implement a practice change to improve teamwork and patient safety.
Methods: Project procedures that took place in the week preceding implementation included education for twenty-six charge nurses on the correct utilization of the institution’s validated critical event debrief tool, adopted from the Immediate, Not for personal assessment, Fast facilitated feedback, Opportunity to ask questions (INFO) tool. During implementation, charge nurses serve as facilitators and conduct post critical event debriefs with multidisciplinary team members using the debrief tool after qualifying events. Qualifying criteria for a debrief put in place by the institution includes cardiac arrest, difficult airway response, extracorporeal membrane oxygenation (ECMO) team activation, emergent intubation, self extubation, massive transfusion event activation, chemical code, and patient falls. Weekly, completion of the debrief tool is audited by the QI team lead using the audit tool, beginning after week one of education throughout the 15-week period. Additionally, the stakeholder team analyzes debrief feedback for QI themes for teamwork and safety through the weekly audits of the tool.
Preliminary Results and Conclusions: In the thirty days prior to implementation, there were fifty-eight eligible events, twenty of which were rapid response utilizations or cardiac arrests. Of these events, zero debriefs were documented. Currently, the project is three days into implementation. There have been no eligible events for debrief thus far. However, ninety two percent of the charge nurses were educated on the facilitation of debriefs. Structural goals were one hundred percent met in placement of quick response (QR) codes at all nurses’ stations and huddle rooms on the unit. Baseline data and goals projected for the implementation thus far suggest that there is a large opportunity for improvement in adherence to debriefing critical events. Based on the existing evidence, there is a predicted positive association between this implementation and an increase in teamwork and patient safety. The study is ongoing and will be completed December 2023.
Description
Learn how the implementation of a validated, post critical event debrief tool affects collaboration among the healthcare team and safety in the patient population in a high acuity, high pressure setting.