Implementation of "Patient Behavioral Debriefings" in a Medical Behavioral Unit to Improve Care for Behaviorally Complex Patients, Including Patients with Autism Spectrum Disorders

Background: Post-event debriefings are a foundational behavior of high performing clinical teams (Sawyer T et al, J Perinatology, 2016). A solid literature base supports the utility of such facilitated discussions of significant clinical events for educational and quality improvement purposes. Debriefing as a post-experience analytic process of learning has a well-documented impact on bettering patient care, improving teamwork, elevating communication efforts, upgrading organizational systems, equipment and resources, supporting emotional processing of participants, and educating providers. As adult learning theory highlights that educational efforts are most effective when a topic is both relevant and carries emotional impact (Edelson DP, Arch Intern Med 2008; Fanning RM, Simul Healthcare, 2017), serious, unexpected, traumatic, and ineffective patient care events are important learning opportunities.
Objectives: To implement post-event debriefings in a Medical Behavioral Unit (MBU), a 10-bed inpatient medical unit at Children’s Hospital of Philadelphia (CHOP), to enable iterative improvements to patient care.
Methods: The Medical Behavioral Unit provides care and support to behaviorally complex patients with medical needs. To develop a systematic approach to debriefing behavioral events, the CHOP debriefing tool for medical events was adapted to identify a consistent process and approach to debriefings after patient behavioral events. This tool for debriefings, was implemented in February 2017 focusing on setting a collaborative tone and clear format for interdisciplinary discussion and improvement in patient care.
Results: The multi-disciplinary team, which includes Psychiatrist/ Psychiatric Nurse Practitioner, General Pediatric Hospitalist, Pediatric Acute Care Advanced Practice Provider, Nurses, Psychologist, Social Workers, Case Management, Child Life, Board Certified Behavior Analysts, Senior Nurse Aide, and Psychiatric technicians, now regularly debrief patient behavioral incidents in the MBU. This has led to rapid and highly individualized changes to care plans for MBU patients, whether a change in medication, or a team-wide change in how to approach the patient. The debriefings have enabled the entire team to more accurately understand patient needs and triggers and to adapt to those needs across disciplines. The debriefings have also led to more general changes in practice, for example the establishment of weekly scheduled meetings to discuss the ongoing care plans for long length of stay patients, and the development of consistent daily schedules to support patients with scaffolding and managing expectations. The consistency of schedule and the ongoing adjustments to care plans have been particularly helpful in supporting patients with autism spectrum disorders who benefit from structured routine, and have highly individualized behavioral triggers and needs. To date there have been 35 debriefings completed on the MBU since February 2017 on 23 unique patients.
Conclusions: The new model of debriefing in the Medical Behavior Unit where post-event inter-professional discussion leads to immediate changes in plans of care related to behavioral support, provides a mechanism for continuous review of unit processes and best practices, and has led to improved patient outcomes for children with ASD and other behavioral needs.