Guidelines for Critical Incident Stress Management. Certified Registered Nurse Anesthetists (CRNAs) provide high- quality anesthesia services and are personally invested in the continuing health, safety, and welfare of their patients. The Institute of Medicine report, To Err is Human: Building a Safer Health System sparked a nationwide call to design systems of care that decrease risk of error and enhance patient safety. The American Association of Nurse Anesthetists (AANA) embraces patient and healthcare provider wellbeing and safety. The AANA recognizes that the physical and emotional wellbeing of CRNAs and Student Registered Nurse Anesthetists (SRNAs) is the foundation for practice excellence. Critical incidents are inevitable in healthcare, possibly causing significant, long term health issues for patients and those who care for them. Other terms that may be used include sentinel event and traumatic incident. It has the potential to exhaust one's usual coping mechanisms, resulting in psychological distress and disruption of normal adaptive functioning. These events are typically related to a breakdown in the overall health system or process, rather than the negligence of one individual. Adverse event. The error may or may not lead to patient harm. When a critical incident occurs, a cascade of emotions may overwhelm an otherwise healthy individual’s coping skills. For this reason, healthcare providers involved in critical incidents are often termed “second victims.”1. Second victims are affected by the impact of the incident on the first victims. Relationship between acute stress and post- traumatic distress disorder following a critical incident. Management of Traumatic Responses. The CRNA and SRNA have provided the supportive environment necessary for the patient’s understanding and recovery, but as the second victim, the anesthesia professional may require the same support as they move through their personal coping process. Crisis interventions support all victims impacted by a critical incident, and help second victims understand and normalize their emotional reactions and prevent long- term consequences, such as PTSD. Guidelines and information on the debriefing process following team building activities.Examples of specific debriefing techniques used following team building activities. Discusses Acute Stress Disorder (ASD), including who is at risk, how is it treated, and how is it related to PTSD. These interventions may include debriefing, counseling, screening for the need for longer- term therapy, and referrals for further mental health treatment. The most commonly utilized interventions are briefly described below. Intervention Strategies for Managing Critical Incident Stress. Critical Incident Stress Management (CISM) Model. The CISM model is a comprehensive, multicomponent program to maintain or restore the individual(s) involved to their usual state of health by alleviating the severe effects of traumatic stress. The interventions are conducted throughout three stages of the model: pre- crisis, acute crisis, and post- crisis to address preparing for an incident, the reactions that immediately follow an incident, and the possible long- term effects from experiencing a critical incident. Critical incident stress management model may be used by individuals, families, and organizations and should be facilitated by trained personnel. The seven core components of CISM are briefly discussed below. Debriefing is a process of: receiving an explanation, receiving information and situation-based reminders of context, reporting of measures of performance, and/or opportunities to further investigate the results of a study. Participants will be able to: Articulate the purpose & value of debriefing List 3 techniques for every type of debriefing List 2 debriefing techniques that are beyond the “review-of-events” Objectives. Critical incident stress management (CISM) is an adaptive, short-term psychological helping-process that focuses solely on an immediate and identifiable problem. It can include pre-incident preparedness to acute crisis. If you’ve been through a major crisis, you know it’s not always easy to get your life back to normal. WebMD describes how a critical incident stress debriefing (CISD) can help you get better. Debriefing -- Missionary and Christian Leader Care. Debriefing is setting aside time for sharing your story, guided reflection, and finding new perspectives from God to empower your life. A field study of critical incident stress debriefing versus critical incident stress management. Journal of Mental Health, 10, 351-362. Vogt, J., Leonhardt, J., Koper, B. Pre- Crisis Stage Intervention Pre- crisis preparation. This phase of the model occurs prior to a critical incident. It includes stress management and stress resistance education, instruction in relaxation techniques, and developing and strengthening coping skills. The goal of this brief session is to immediately assist individuals in understanding and managing their preliminary reactions to the event. Defusing. A defusing session is an extension of the demobilization and consultation session and occurs after the work day, but before the involved parties depart for the day. This session is conducted by a person of authority and typically lasts an hour. The purpose of this intervention is to recount the details of the event, provide information about potential emotional reactions, offer support, and allow individuals to express his or her concerns surrounding the incident. Fatigue: Symptom — Overview covers definition and possible causes of fatigue, such as fibromyalgia and sleep apnea. Critical Incident Stress Debriefing (CISD)Critical incident stress debriefing was originally used for emergency service workers, but has been found to be useful in the healthcare field. It is highly recommended. CISM. 1. 7,2. 5 CISD is designed to accompany the other components of this model and should not be used as a stand- alone intervention. Emotional support, better mental health of the group, increased job retention, reduced symptoms, and increased productivity are reported benefits of CISD. The seven phases of formal debriefing include introduction, fact phase, thought phase, reaction phase, symptom phase, teaching phase, and re- entry phase. One- on- one crisis intervention. Crisis intervention includes counseling or provision of psychological support throughout the full range of the crisis spectrum. The goal is to guide each person back to the level of functioning prior to the incident. Family critical incident stress management. Critical incidents have a significant and devastating impact on families. Family crisis intervention supports the family, promotes patient- provider communication, and provides direction towards closure. Post- Crisis Stage Intervention. Follow- up and referral for treatment. Critical incidents have overwhelming effects on all parties involved. There may be a need for long- term psychological treatment. Therefore, it is important that a follow- up and referral mechanism is established for anesthesia providers and their families. The facilitator then asks an ice breaker question to create a sense of cohesion amongst the group. The team is encouraged to share any concerns that could impact patient care. Once the briefing is complete, the surgery commences. The debriefing stage has an educational tone and may include encouraging remarks regarding the procedure. It may also be problem- solving focused, aimed at identifying and discussing near misses, equipment deficiencies, and/or patient safety issues. This method has been reported to improve interdisciplinary communication and teamwork in the operating room,2. Considerations for Critical Incident Stress Management Program Development. Currently, few facilities have established CISM policies,2. CRNAs report feeling underprepared to cope with the after- effects of a critical incident. Professional interventions in the workplace are beneficial to both healthcare providers and patients and are essential to ensure quality healthcare. Critical incident stress management programs support development of healthy coping mechanisms and may improve work engagement with associated reduction in stress- related illness absences. Key elements to consider in establishing a CISM program or policy: Preparation Component: To provide education regarding critical incident stress and what to expect when an incident occurs. Prevention Component: Training in relaxation techniques that may provide comfort to prevent the coping system from being overwhelmed. Debriefing Sessions: These are strongly encouraged for healthcare providers involved in a critical incident, but not be mandatory. They should also be available on request by any member of the healthcare team. Interventions: Led by mental health professionals who are experienced in the debriefing process and not directly involved in the critical incident. Confidential and Non- judgmental: All intervention participants should be assured that all discussions are confidential and non- judgmental. Evaluation Process: Evaluation of the CISM program following the event provides staff with the opportunity to reflect, assess the effectiveness of the program and contribute to the ongoing improvement and engagement with the program. Strategies for Implementing a CISM Program or Policy: Management support of a CISM program is vital for the program’s success. Management and supervisory staff should be trained prior to implementing the CISM program facility- wide. When educating staff, emphasize that management fully supports the policy. Develop a robust policy communication plan that includes how to access support resources for those who are experiencing traumatic stress or have been involved in a critical incident. Extensively communicate through vehicles such as staff meetings and notices posted throughout the facility. Seek employee feedback so questions and concerns may be addressed. Provide continuous educational opportunities after the policy has been implemented to support employees and encourage use of services. Disclosure Communication is a key factor in both preventing and coping with critical incidents. It is imperative to establish open and effective communication with patients and their families. There are three types of disclosure: 3. History of Disclosure. Historically, disclosure of critical incidents to patients was rare due to concerns about professional preservation and fear of litigation. In recent years, national and international governments, accrediting bodies, and healthcare institutions have taken measures to address acts of disclosure. Patients have reported a desire and expectation to be informed of the outcomes of their care. Patients are unable to make informed decisions and consent to subsequent treatment if they are not completely aware of the adverse event. In addition to serving the patient, disclosure creates an opportunity for the provider to validate the patient’s concerns and to offer empathy which may emotionally benefit the healthcare provider as well. Some accrediting organizations, such as The Joint Commission, have added language to their standards requiring licensed practitioners to disclose unanticipated outcomes to patient and families. In addition, ethical and professional codes of conduct encourage the disclosure of unanticipated outcomes to patients. Western Massachusetts Emergency Medical Services Inc. Through its work, the Committee evaluates and sets standards of quality for regional EMS, offering training, education and medical services research opportunities and developing appropriate protocols and policies for implementation. As a regional corporation, the Committee seeks regular input and broad representation on its board from the communities and consituencies it serves: consumers, municipal governments, hospitals, ambulance services and other providers of emergency medical services across the four county area. There are five regions in Massachusetts. Western Massachusetts EMS serves Region 1, which includes Berkshire County, the majority of Franklin County, Hampden County. September 6, 2. 01. The updated Protocols, and the Department.
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