• Domenic R Cincotta, Nuala Quinn, Joanne Grindlay, Stefano Sabato, Emmanuelle Fauteux-Lamarre, David Beckerman, Terry Carroll, and Elliot Long.
• Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.
• Emerg Med Australas. 2021 Oct 1; 33 (5): 780-787.

ObjectiveIn 2013, our intubations highlighted a safety gap - only 49% achieved first-pass success without hypoxia or hypotension. NAP4 recommended debriefing after intubation, but limited published methods existed. Primary aim is to implement a feasible process for immediate debriefing and feedback for emergency airway management. Secondary aims are to contribute to reduced frequency of adverse intubation-related events and implement qualitative improvements in patient safety through team reflection and feedback.MethodsA component of a prospective quality improvement (QI) study over 4 years in the ED of the Royal Children's Hospital, Melbourne, Australia. Debrief and feedback after intubation was one of seven study interventions. Targeted staff training and involvement of departmental leaders occurred. A post-intervention cohort was audited in 2016. Analysis included the Team Emergency Assessment Measure.ResultsImmediate post-event debriefing occurred in 39 (85%) of 46 intubations. Debriefing was short (median duration 5 min, interquartile range [IQR] 5-10) and soon after (median time 20 min, IQR 5-60). Commonest location was the resuscitation room (92%), led by the team leader (97%). Commonest barrier preventing immediate debriefing was excessive workload. Two QI process measures were assessed during debriefing (adequate resuscitation, airway plan) and case summaries distributed for 100% of intubations. Performance outcomes included contribution to 78% first-pass success without hypoxia or hypotension. Team reflection prompted changes to environment (signage, stickers), training (skill drills), teamwork and process (communication, clinical event debriefing).ConclusionStructured and targeted debriefing after intubating children in the ED is feasible and contributes to measurable and qualitative improvements in patient safety.© 2021 Australasian College for Emergency Medicine.

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