Incorporating debriefing into clinical practice

plus delta pic
Plus - - - Delta

I'm in the middle of an intense weeklong course on debriefing for medical simulation here in Cambridge, MA. One of the goals many of the participants share is our desire to improve our skills in the art of debriefing after clinical simulations. Although the course focuses on "Debriefing with Good Judgement"* today the faculty also offered a simple tool to structure a brief debrief when time is very limited.

The Plus/Delta Chart seems like a good structure for after-action debriefing in the ED where we are always pressed for time. There is debate on the origins of this tool; some posit that it arose in the aviation industry while others claim that it originated in a 3rd grade class room.

Could I bring the Plus/Delta to the Emergency Department?

After an intense or stressful case such as a trauma activation or cardiac arrest I find that many members of the team want to talk about what happened, how the team performed, and what could be done to improve the care we provide in the future. I have found that gathering everyone is often difficult but taking 5 to 10 minutes to talk among most of the people involved is probably feasible.

To create your own form, take a blank piece of paper and draw two straight lines in the shape of a "t". Label the first column with a plus-sign and the second with the symbol Delta. Once we've recreated the tool, we might follow these three steps:

  1. Set the stage for debriefing by gathering the team, describing the exercise, and stating a time limit i.e.: "we will end at 10:45".
  2. Inquire about your team's thoughts on the case eliciting first many of the POSITIVE aspects of the resuscitation. This is an opportunity to highlight things that went well such as the availability of uncross-matched blood at the bedside or the fact that the paramedics were able to give their report without interruption.
  3. Move on to the Delta side of the chart and record aspects of the event that team members wish had gone better and that they hope to improve on the next time they are faced with a similar situation. An action plan such as: "I'll ensure that the ultrasound machine in the room next time we he hear that we are getting a critically ill patient" (one of mine from last friday) could make those "Deltas" concrete, explicit, and shared.
I have used this tool in debriefing teams in the simulation lab and found it useful to organize the collective thoughts of a group. I think it is a really helpful tool because as caring, highly trained and skilled emergency nurses, doctors, surgeons, paramedics etc., our default mode is to focus on all the things that went wrong or could have gone better. Surfacing those positive aspects first not only recovers team and individual morale but also records and displays behaviors worth repeating and sets goals for the future.
  • Have you used this tool in similar or different ways?
  • Have you found it useful or easy to apply in the clinical setting?
  • Who usually runs these debriefings in your institution?
  • Do you use another strategy?

*Rudolph et al. There's no such thing as "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Simulation in healthcare : journal of the Society for Simulation in Healthcare (2006) vol. 1 (1) pp. 49-55 [PMID]

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