Abstract
Intensive Care Unit staff deal with potentially traumatic cases throughout their careers. We designed and implemented a ‘Team Immediate Meet’ (TIM) tool, a communication aid designed to facilitate a two-minute ‘hot debrief’ after a critical event, provide the team with information about the normal reaction to such an event and signpost staff to strategies to help support their colleagues (and themselves). We describe our TIM tool awareness campaign, quality improvement project and subsequent feedback from staff who reported that the tool would be useful for navigating the aftermath of potentially traumatic events and could be transferable to other ICUs.
Keywords: Wellbeing, debrief, traumatic events, intensive care unit, mental health
Introduction
It is inevitable that staff working in intensive care units (ICUs) will encounter difficult cases. 1 Trauma Risk Management (TRiM) is a peer support tool developed by the UK Armed Forces to help troops prepare for and recover from potentially traumatic events.2,3 Although we introduced TRiM in Bath in 2012 following an ICU fire, 4 it was not used to its full potential. 5 We therefore designed and implemented a communication aid for use immediately after a critical event 5 with the following aims: first, to assist and empower staff to lead a short ‘hot debrief’, even if affected by cognitive overload; second, to record names of all staff involved immediately to facilitate supportive follow up, as it is difficult to do this after the event; third, to encourage TRiM referrals to be made using full names and email addresses of staff involved; fourth, to provide staff with information about common feelings and suggested actions - based on the Principles of Psychological First Aid, advocated by the World Health Organisation, 6 and the ‘PIES Principles of Cooperative Learning.’ 7
Following implementation of the first version in 2020, 5 we collaborated with Intensive Care Society staff to optimise the wording, layout and design of this tool. We produced a second version, re-named the ‘Team Immediate Meet’ (TIM) tool (Figure 1), including our hospital TRiM team email address. Other hospitals could potentially personalise the TIM tool by adding their own staff follow-up email address.
Figure 1.
Team Immediate Meet tool - RUH Bath version.
Methods
Laminated copies of the TIM tool were displayed in ICU central locations and staff coffee rooms. We designed and delivered an education and awareness programme for our ICU multidisciplinary team in 2021, using the ‘Tea Trolley’ training method, 8 and comprising 5–10 min ‘bite sized’ bedside teaching sessions: these covered the TIM tool’s purpose, location and when and how it should be used. Immediately after teaching, participants completed a short questionnaire rating their perceived confidence in using the tool and its potential benefit, plus an opportunity to share situations when this tool may have been useful.
Staff feedback was used to drive further improvements with a third version (Figure 1) launched in September 2021. To assess implementation, we analysed the hospital’s TRiM team’s records to measure the number and completeness of TRiM referrals and surveyed ICU and TRiM team staff.
Results
Fifty-three staff participated in the education and awareness programme using the TIM tool second version: ICU nurses (52%), doctors (18%), health care assistants (16%), advanced critical care practitioners (4%), trainee nurses (4%), physiotherapists (4%), ward clerks (2%). Feedback form return rate was 100% with staff reporting that they felt very/quite confident in the following: leading a ‘hot debrief’ using the TIM tool 43% prior to teaching and 92% afterwards; locating the TIM tool 15% before teaching and 72% afterwards. Staff reported that the following statements about the redesigned TIM tool were definitely/maybe correct: would prompt the team to make a full list of staff involved (100%); easier to use than the previous version (67%); would improve their ability (95%) and the team’s ability (99%) to navigate the aftermath of a potentially traumatic event (95%). All staff reported that they would recommend the TIM tool to other hospitals. Staff free text comments and examples of situations when the TIM tool may have been useful in the past are shown in Table 1.
Table 1.
Staff free text comments and examples of when they felt that the Team Immediate Meet tool could have been useful.
| Staff role | Comment |
|---|---|
| Nurse in charge | “I think this is brilliant as I often get home after a night shift, think that I should have run a debrief after a difficult case but that we didn’t manage to fit it in. I really worry about my team when I get home, and this is something practical that will help my wellbeing as well as that of the team” |
| Senior doctor | “A child died in ED when I was an F2 and it was so busy that I was just expected to carry on seeing patients for the rest of my shift. I remember suturing up a patients face with tears rolling down my cheeks. If we had had a mini debrief like this it would have really helped me. I am still feeling tearful about that shift, and it was over 10 years ago” |
| Band 6 sister | “I was really upset for 2 days when looking after the 18-year-old patient who had a cardiac arrest a few weeks ago– so much so that I woke every hour and rang the ICU at 4 a.m. when I thought he’d be going for organ donation. Maybe we should think about doing an end of shift mini debrief as well as this?” |
| Sister | “I love the structure of this. Even if my head were in a spin and/or I was too upset to think I’m sure I could read this out” |
| Senior nurse | “I talk into my phone on my way home to ‘empty my head’ of what has happened, especially if there have been some tricky times that day. It’s just for my own use, but I save it in case I want to listen to it again.” |
| Ex-senior nurse, now doing retired but working ICU bank shifts | “I initially thought ‘why do we need this when we’re already very good at dealing with difficult events?’ but on reflection I think that this could’ve been extremely useful to me when I was the nurse in charge, especially during night shifts. I think that the burden of looking after my team really took its toll on me and this would have been a way of helping me to support them” |
| Band 6 sister plus band 5 nurse | “We like the fact that two of us could read this out together especially when we are doing night shifts with new junior doctors” |
| Band 5 nurse | “I like the way that it is on the wall by the drug cupboard so that we can get it quickly and easily” |
| Band 5 nurse, recently started working on ICU | “I had a really tough shift last week looking after a very agitated patient that I didn’t seem to be able to settle. Reading this really helps me realise that difficult shifts on ICU are to be expected and if I find them hard then that just shows that I’m a caring nurse – not weak or incompetent” |
| Band 6 sister | “It never fails to surprise me how upset I get sometimes at work – looking after patients and families going through such difficult times – but this teaching today has reminded me that it shows I’m caring and kind and the day that I don’t feel upset is the day I should stop doing this job. Thank you.” |
| Senior band 6 nurse | “I found last Wednesday really tough, as I was looking after a lady in bed 10 and that was the bed that my mum was in when she was an ICU patient. No one realised though and I did not tell anyone. I’m realising now that maybe I should have shared with my colleagues that I was struggling that day and why – this teaching has made me realise that it is normal to find things like that tough.” |
| Brand new ICU nurse | “I had a terrible shift on Monday looking after a very distressed patient and the information on the back of this TIM tool would have been really useful. I’m going to read it later in the coffee room.” |
| Consultant | “No-one has ever really shown me how to lead and run a mini staff debrief, and this will be really very helpful. Thank you.” |
| Staff grade doctor | “Ten years ago a patient had a cardiac arrest and died in our theatre recovery ward, and the nurse in charge there asked me to lead a debrief for the staff. I was very upset as it was a patient that I knew well who had died, I wasn’t sure what to say or do, and this stress added to my (already extreme) anxiety. This TIM tool would have really helped in that situation – the nurse in charge could have read it out himself, or we could have read it out together.” |
Following the launch of the third version, the hospital TRiM team reported the following improvements to TRiM referrals: increased numbers; made by a wider range of staff and more quickly after an event; less time required to chase full names of staff involved. Four multidisciplinary team ICU staff who had used the TIM tool following a critical event in the preceding month participated in the follow-up survey, with all reporting that the TIM tool would ‘definitely’ or ‘maybe’ result in the following: help staff lead a hot debrief; provide a prompt to make a TRiM referral; make the TRiM referral process easier; and provide a prompt to include a full list of all staff involved. All recommended the TIM tool to other hospitals.
Discussion
The TIM tool was well received by our multidisciplinary ICU team, who reported that it would increase their confidence to lead a ‘hot debrief’ and help the team following a potentially traumatic event. Preliminary feedback one month after implementation was very positive.
Staff stories suggest that staff may benefit from a hot debrief in many situations: the TIM tool is a simple and inexpensive strategy that may assist ICU teams in doing so, and in improving staff wellbeing following a critical event we may also improve patient safety. We believe that this tool would be easily transferable to and reproducible in other ICUs, plus other areas of the hospital. It is currently being trialled in Cardiff ICU, with the ICU clinical psychologist’s email address used to provide supportive follow up.
A limitation of the TIM tool is that it does need to be associated with a formal governance system to follow up staff involved in a critical event, such as a TRiM team or a clinical psychologist working as part of an ICU team.
Acknowledgements
We thank Drs T. Johnson, F. Millinchamp, M. Osborn, S. Shatwell, K. Herneman and S. Gouldson, Ms Simona Hanson and the Intensive Care Society graphic design team for their work and contributions towards the development of the TIM tool.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Matthew Edmondson https://orcid.org/0000-0002-6064-230X
Layla Guscoth https://orcid.org/0000-0003-4917-0425
Fiona E Kelly https://orcid.org/0000-0003-3076-0118
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