Kim Zaky DNP, RN & Julia Afrasiabi: Asynchronous Debriefing Process (2/28/25)

Okay, welcome everybody. It is the end of February, February 28th. It's Friday at 11:00am I'm Peter Anteby and I'm joined by my co host, Tanner Smita. And this is another Florida EMS webinar where we bring the best and the brightest through the webinar. Most of the time these are topics that you haven't heard of before. They're very unique and today is no different. I met Julia and Kim in California when I was in the CFED conference speaking and I was fascinated by what they are doing and I begged and pleaded for them to actually join the webinar and they accepted. So both Julia Afrasiabi and Kim Zaki are working at UCI Health which is in California. They're program managers. So Kim is a program manager for the Burn center, but she has 20 years of experience in EMS pediatrics and trauma. Julia has 18 years of EMS trauma and ER experience and she's a pre hospital care coordinator at UCI Health. And wait till you hear what they're doing. Many of you know that when you have a case in ems, you bring it in and you really have no idea what happened after that. They really put together a very unique debriefing process that I wanted all of you to hear about. So without any further ado, kid. Kim and Julia, thanks for joining the Florida EMS webinar and take it away.

Thank you.

Thank you for having us. I'm Kim Zaki and this is Julia. And we appreciate the opportunity to share how we developed and implemented an asynchronous.

Debrief process from EMS through inpatient. So a little bit about why and then our why. We know that high stress and busy teams such as EMS and busy EDs do not routinely have the opportunity to debrief critical events. We do know that a lot of times if they do, it is very informal, it is not recorded and sometimes that information does not get disseminated out to entire teams. We also know that without these debriefs and follow through, we could have decreased closures and leave open ended problems without this tool. Traditionally, debriefs focus on review, but more and more information that is coming out shows that debrief sessions can lead to identifying education needs and system process changes. We also know that a debriefing tool can lead to increased patient safety by addressing process issues, knowledge gaps and clinical skill improvements. So by implementing a consistent just culture debriefing process, leaders can create a nonjudgmental form that supports psychological safety and performance improvement. So this is my why and you may seem baffled about why I'm hugging a wall. I do have over 20 years of pre hospital AD trauma experience. I have spent basically all my life as a radio nurse working with ems. I was given a once in a career opportunity when I was at a children's comprehensive center to open a peds only base station. So with that came a lot of research protocol building. And for our department, we would see 300 to 500 pediatric patients per day. That's how busy our ED was.

Most of them came by private auto. Not a lot of our patients, especially peds patients, came by ems. And when we started looking at the data, the county data, we realized that out of all of the EMS transports in our county, only 1% of the transported patients were pediatric patients. So that by default tells us that pediatric interactions are low volume. So not only are pediatric patients low volume, they also have very little pediatric education opportunities.

It was my goal and what I committed to was making sure that I was able to provide a detailed outcome on every single base contacted call that came to us. I wanted to feed back this information and I was surprised with some of the feedback that I got in response. And I'll list a couple of them, you know, thank you. I was very worried about this kid. So we have EMS providers who maybe brought in a febrile seizure that we see multiple times a day, but maybe that was their first time seeing a seizure patient. I've been a medic for over 10 years. This was the first time I have ever given EPI for an allergic reaction. So again, low volume medication dosing. Thank you for sending good outcomes and not just the bad ones. And this to me reinforced how important it is to, you know, give compliments to your assessment and intervention skills. And this by return increases confidence in the provider. So this whole process made me realize how important offering an opportunity to debrief and creating a just culture environment really was.

And then mine is a little more personal. Not that hers was not personal. Hers was very personal. But about two years ago, my brother, actually, the week of CFED, Dr. Hani, got hit by a car. He was driving his motorcycle home from work one night and was hit by a car. And that's him in the middle pre accident. The picture on the right is him in the ICU a few days after his event. I remember when my mom called me thinking, okay, my first question for her is, is he dead? No, he's alive. Okay. Does he have a brain injury? No, his brain's fine. Okay. What about his spine? His spine is okay. Okay. What about his internal organs? There's no bleeding. Okay. So we're going to be okay. We can get through this, right? Like as a trauma nurse, you just go through the worst case scenarios and you run through it and it was very strange and out of body to realize that things that we do every day can happen to us too. So really that wasn't where it clicked for me that this is something we needed in our system. It wasn't until a little later when he was finally up and walking and moving, which took a long time. It was nine, ten months later when he walked himself into the Berkeley Fire department to meet the two medics who scraped him off the pavement. And when he walked in, I will keep the expletives out of their response, but what they said was, holy bleep, we thought you were dead. There's no way you should have survived that. So in their heads, for 10 months they had been processing, scooping a 30 something year old young man off of the ground and that he died when that was one, not the case at all. 2. Their interventions saved his life. The medications they gave him the in the field actually stopped his bleeding. And they never got any of that information until he walked in himself as a patient. So for me, that really made me realize how much of a gap we had in our pre hospital and our system when it comes to loop closure and debriefing. So what we started talking about before we really got into the asynchronous, right, like you got to spend a lot of time thinking about what, what you need to work on. And what we first looked at was burnout. Right. So those of us in this field know burnout is rampant and we'll talk about data in a little bit about that. But burnout is not something to sniff at and burnout is definitely not something that we wanted to ignore when we looked at pursuing this asynchronous idea. So we did a little research and the first definition we found was that burnout is a state of emotional, physical and mental exhaustion caused by prolonged and excessive stress. Okay. That's literally every single pre hospital staff member I've ever met in my life. We have prolonged excessive stress all the time. Right. But this is the one that really caught our attention was the World Health Organization calls it in that it burnout. In our area, health care they identified as an occupational phenomenon which is mind blowing. And the result is chronic workplace stress that's not been successfully managed. And that's where we started to get the spidey Tingly of. Okay, yes, we know it happens, we know it's a thing. But the real problem is, is it's not being taken care of at all.

So what does the research show? And I'm not going to belabor these statistics because it's something that we already know is that there is burnout. This was pre pandemic. So even before we kind of, you know, put our system in more stress, 37% of prehospital and 40% of the hospital setting were just over it, fed up burnout. Why? So in the pre hospital setting, it was identified that it's the constant exposure and re. Exposure to traumatic events, the long working hours and the emotional demands of the job. In the hospital setting, it is increased patient acuity, inadequate staffing and emotional demands.

Also, it was noted in a study that, you know, for the majority of EMS personnel staff, they either are over it, like they are neutral on if they want to continue in this field all the way to. They strongly agree that they do not want to work in EMS anymore. And I'm sure this data is also outdated since this is 2023. But post pandemic, the numbers are just going up with how burnt out everybody is in health care. 20% in EMS post pandemic.

So when we saw all this data, we were thinking, okay, so we know burnout's a thing. We know it's only getting worse. Nothing's being done about it. I mean, the World Health Organization recognizes this. It's not just us two little nurses in a car driving around thinking about genius ideas, right? So what are we going to do about it? And this is where we kind of thought there could be a very direct relation between debriefs and combating burnout. But how do we do that when we're working in different settings? Right? So we want the same thing. Part of the need is related to the full care of the patient. So why not look at the continuum of care? Why not look at from the moment a patient needs health care, I. E. Calling 911 and needing pre hospital all the way through till their ICU stay, their acute 24, 48, 72, 92 hours is done. Right? And that's kind of where our focus then will was able to be pulled into focusing on. We jokingly laugh about this, that we called it a journey on the gurney, but it really is. It's when the patient hits that first need and then the wheeling of them all the way through, all the care that they get provided. And the biggest thing we realized was hold on this is great. We want to address this whole continuum, but how are we going to do it when this continuum. The care teams are disparate, right? So these teams, the definition of disparate teams, I'm sure everybody knows this, but it's where there's a markedly distinct and the groups are made up of different elements, meaning you have your paramedics, you have the crew that run on them, you have your trauma staff that cared for them, you have your burn ICU staff that took care of them or the trauma ICU staff. And I think the biggest point to I don't want to belabor but really highlight is nobody's physically located together ever. They're never, unless it's at handoff, they're never in the same spot. So in order to actually get their input and get their thoughts and look at the system, it would take us three years to get one team together. So we really wanted to identify the areas we could focus on. If we did start to want to focus on the disparate team.

Some areas that we thought we could absolutely not just identify but actually address were things like misconception. Misconceptions during a debrief, they can be corrected. So you think something and then in your debrief as you're talking you realize, oh wait, no, but maybe that's not what it actually was. Or maybe, oh, you're right, that was, that is the correct dosing. I just second guessed myself.

Secondarily. The validations of observations I think are huge to Kim's point earlier when she was talking about her. Why you have no idea how many times we have medics come in and go, I don't know what it is, but there's something about this patient or my gut was telling me something was wrong. And these and debriefing it can validate that because you get the outcome here. Oh, that's what was wrong. No wonder I thought something was off. It was hard to pinpoint, but I knew. And. And then lastly we really wanted to focus on non threatening so we don't back to that just culture mindset. We didn't want it to be as if we were debriefing because something needed to be educated to you or you made a mistake. Right? So our by, by focusing on these, it allowed us to really look at what we could build.

And in that brainstorm time we realized debriefing is not a one and done ever. It is not a. Okay, I did my one debrief with my team for those of you on this call or on this video who have done debriefs. You know, things come up later, more questions occur, you have your hot debrief, you then wait a few weeks and you bring in, you know, an expert because some kid had a random disease process nobody knows about. And so you have a cold debrief about that. But it, but it, it's never done. So we could very strategically fit ourselves into where it's never done. Let's be the first point of access for them to be able to provide their thoughts and give their feedback on a call.

We definitely ran into and made assumptions, but we definitely ran into a lot of barriers. Biggest one is the lack of synchronization. Not able to find anybody anytime. Everybody works different shifts. A shift is picking up a B shift call with a C shift guy who needs overtime for his vacation. It was a nightmare. The other thing we definitely ran into, especially you know, in the pre hospital setting was that fear of admitting that there was the potential that things weren't done exactly how they should have been done so that that self protective mechanism kicks in. There's also, you know, that mindset of what's the point? We talk about these and nothing changes. We bring this up all the time to our fill in the blanks and nothing gets better. So what's the point of even talking about these cases anymore. The other things we found kind of to feed off of what I just said though was the scheduling. Getting people to sit down at a table at the same time was near impossible. The other part that we found was in a hospital setting everybody needs breaks. This person's on a break and that person's not back yet. So before you know it, it's end of shift. So we were running into that problem in our hospital setting once they did reach our doors. And then the other one that we really felt pretty significantly was the facilitators were really difficult. You can't just have anybody run a debrief. Somebody just can't step and be like, okay, we're going to debrief because that's not going. There are specific steps and there's been a lot of research in how a, a well thought out debrief is run by a well trained facilitator. But arguably our biggest challenge was we are busy. I'm sure this looks nothing like how busy your ears actually are because this was a Google image. If I took a picture of our real ER right now, it would look like much worse, but then even more so you guys are busy out in the field. Call volume is only exponentially increasing by the year. I just watch it tick up. So the busyness factor is hugely influential in whether patient or people who have had a call are going to be able to sit down and talk about it if they have to go to the next call.

So our primary goals when we went into all of this was.

We knew the future improvement relied on feedback from the staff who are doing this work. We knew research showed that debriefs help. We knew that there's been ad nauseam amounts of information out there on how it's beneficial, but nothing was being truly actively done consistently. So if we know it's going to help, why aren't we doing more? So we had to pivot, we had to adapt our mindset. So we decided instead of trying to chase people down, we changed the forum that the debrief was provided in. And that's where asynchronous debriefing comes about.

We wanted to provide a forum where the staff members who are involved in complex, high stakes cases had the opportunity to give their input, share what went well, acknowledge what could have gone better, acknowledge their colleagues. This was a big one. What colleagues did you work with that really did a great job? You'll see later on how absolutely positive that piece was and we wanted it in real time. And what we figured was if we could get pre hospitals feedback and we could get the inpatient ICU feedback and we could get the ED trauma feedback. That little sweet spot in the middle of that Venn diagram is what we were calling the collaborative system improvement opportunity. Meaning if everybody could come together and provide good insight, we probably, hopefully possibly could move towards improvement of our system from the perspective of the people who were working within it. Some considerations that we definitely want to point out as moving forward. We're going to talk about our framework. This does not replace the in person debriefs that pre hospital does. This does not, you know, take the place of your hot debriefs and your peer support and all of that. This does not replace your incident reporting. So if you as an institution or a prehospital have incident reporting, that is still in play. It did allow for comments to be done asynchronously throughout the entire stay of the patient. I will say I want to highlight also it did allow for anonymity. So the ability to be honest without your name assigned to it was shockingly freeing for some people. And then it did allow it the end for us to schedule an in person. Sit down, go to your station, go to your unit debrief as well. So those are just some considerations that we tied along with it. And then just very quickly with our timeliness, we made sure that we get alerts every morning. Generally we know before the 12 hour mark after an event has occurred and we will within 20, I like to say sub 24 because I haven't hit 24 hours yet. Fingers crossed. Where we can send out the asynchronous QR code and the asynchronous link for the staff to start providing their feedback basically so that when they get a minute, they can finally get around to it. When they finally get a moment at two in the morning and their brains running on it, they can put their thoughts down. It allowed for significant flexibility on everybody's part, including ours. As the facilitators. We could plan ahead as to when we were going to sit down with them because we knew we had captured real time information already. The information we gathered was so widespread, but really the stuff that we kind of put into buckets were things like the equipment use and needs skill sets. Kudos, like I said, was a big, big one. Communication was another big one. You can imagine when you're looking at patients being handed off multiple times and then processes and policies as well, it allowed us to really dive into those.

So let's just discuss the nuts and bolts of how we implemented this process. So of course we had to start with stakeholder buy in. We had to ask our directors and leaders, our medical directors, you know, we have this idea, is this something that you will support so we can move through? But once we had the leadership buy in, they also said you need to go to Risk management. So we went through Risk Management Management to make sure that we were in compliance with being able to have this information submitted and it's kept under the umbrella of PI. We then met with our pre hospital and in hospital stakeholders. So Julia went to the pre hospital area to discuss with managers, fire chiefs and I went through and talked with the teams, ED and the union.

HIPAA and other considerations. You need to be aware of your own PHA and your organization's expectations. We looked at discoverability. This was protected under our trauma and burn PI groups and privacy we de identified for a systematic review and also the ones that inputted information were anonymous.

We couldn't pick everybody so we wanted to start with a selective high risk group. We did our burns for our patient.

20% of our burn patients come by EMS so the other 80% arrive by different means. So we thought this was still A low volume and very hands on activity in the field with lots of interventions and a lot of movement. Those usually go straight through the ED red line to or or to the unit. Traumatic full arrest. Those are really heavy working calls. Anything pediatric, but specifically critical pediatric traumas. Those are stressful for everybody involved. And precipitous deliveries because that is high risk, low volume, lots of skill sets. So we created QR codes. We have the pre hospital that Julia pushes out. We have the ER trauma debrief and the burn debrief. So they get sent to different locations. We get triggered either by the trauma page that goes out. We get pages for burn, we run a 24 hour report. But honestly I feel staff call us right away or text us. So we either send out the QR code or link to the form. We look to see who is on shift. You know it's important to see who's on because we get a lot of rotating students. So we want students, liaisons, residents, all included to be able to provide feedback. So this is an example of pre hospital. It is matched up using an incident number. There's no patient identifiers other than that.

We started with just the four local agencies that come to us. Most often it is sent through their elite PCR system or email. And then we sent magnets to the fire stations to have if they wanted to send it later on. We created badge buddies for staff and also again we send it out through our Volt messaging system and through the email system. And then there's a burn debrief as well. And what that looks like is we are able to capture the MRN of the patient because you are required to have a university email in order to log in. But it still keeps you anonymous. So we don't collect the names and emails. It's just to get you through that first pass of security.

So let's see it at work.

We had a very significant burn patient come in. We were aware of this case because it was just such a devastating injury. We were able to send off links to the pre hospital ad and then I send it up to the unit as anticipation that you're going to get this patient.

So again this was sent out, everybody had it within 24 hours. The pre hospital, a total of four provided responses and then we continue to get responses throughout the patient stay. And there was a in person debrief requested. So the crew, the EMS crew said you know what, we really want to debrief in person. So these are the kind of comments that we get. What could have been handled differently. The pre hospital personnel said, honestly, I feel like it went pretty well. I could have given a smoother radio package with the details being more organized and less sporadic. Nothing, I thought. The receiving team at the hospital did an outstanding job listening to reports and acting quickly. So a follow up for us would be like, oh, let me go talk to the radio nurse who handled that call. And that radio nurse was like.