Air ambulance transport missions require team members from both the aviation and medical professions to all work in concert to make them successful. While they may well be communicating throughout the flight, a debriefing meeting held at the conclusion of the mission offers an opportunity to discuss what went well and opportunities to improve. A debrief can therefore be considered a useful tool in the pursuit of quality.
David Quayle, Clinical Services Manager at Air Alliance Medflight, suggested that debriefing is a developing trend within healthcare in general, whereas debriefs have long been used in aviation, thanks in part to the military origins of powered flight. The military background can be seen in dictionary definitions of debrief, including Merriam Webster’s, which alludes to pilots sharing information with intelligence information officers. However, in modern medical aviation, the term is used more broadly to refer to post-flight discussions.
Overall, the purpose of any debrief is continual improvement, said Paul Tiba, Managing Director of French provider Airlec Air Espace. The first aspect of this is the practical benefits, as outlined by Denise Waye, President of AirCARE1, who said that debriefs have helped the US-based provider to ‘improve processes as well as led to increased safety and efficiency of operations’. David Quayle echoed this sentiment: “The post-mission debrief is usually about reflecting on what elements went well or badly so that lessons may be learned and systems (plus individual practice) improved.”
Beyond the technical benefits, there are human factors at play too. Waye commented: “Properly done, mission debriefs are a fantastic tool in increasing employee morale by stating what was done well, while providing constructive feedback for improvement.”
Talking over a flight is even more valuable when it’s been a difficult mission. Quayle of Air Alliance Medflight highlighted the need for staff to decompress following traumatic events, adding: “The Royal College of Nursing (UK) states that debriefs should be available to all nurses, while the Scottish Patient Safety Programme includes the concept of the safety huddle involving all members of the multidisciplinary team.”
Providers differ as to whether the whole crew debriefs as one, or whether there are separate channels for medical crew and pilots.
At AirCARE1, debriefs involve all staff involved in the flight process, including medical crew, pilots, operations centre staff and also management, said Denise Waye. Meanwhile, the communications centre performs a separate written debrief that reviews any logistical issues that may have occurred. These reports are reviewed and analysed by management and the outcomes are discussed with the communications centre during regularly scheduled meetings, she said.
Similarly, in Colombia, SARPA also brings together medical and flight crew, said Karen Arbelaez, General Manager, with the aim being to facilitate team integration, cohesion and co-operation of both medical and flight crew. Ultimately, this promotes efficient, safe, high-quality missions, said Arbelaez.
Quayle explained that at Air Alliance, however, post-mission debriefings are usually in the form of a written report for the clinical services manager and medical team and are solely related to clinical and logistical issues. The pilots report back via other systems, he said.
At SARPA, debriefs are led by the flight crew captain and the medical crew chief and follow a standard pattern. The flight crew captain discusses how the mission followed or deviated from initial plans, Arbelaez elaborated: “[We can identify] if there were any difficulties or unforeseen situations presented. If there are, then we can determine what actions are to be improved for the next mission.” Similarly, the medical chief addresses any unforeseen aspects to the medical treatment and how they were handled. Arbelaez continued: “[We] will also make an improvement plan to discuss with the health services directors [so that the event] won’t present itself again.”
The debrief is a great way to elicit feedback and provides a forum to discuss and identify any issues, said Denise Waye. For issues that arise, staff submit a process improvement / hazard identification (PIHF) form. The form identifies the hazard or process that needs to be improved, and the crewmember can also suggest a solution. Waye explained: “The PIHF is then submitted for review where a committee, including management, can analyse and make suggestions that can include new policies, procedures or training. Filling out and submitting a PIHF empowers a crewmember to be part of improving a process.”
Germany’s DRF Luftrettung also uses a reporting system for logistical issues
At Air Alliance Medflight, issues raised from debriefs are revisited in later meetings. Quayle explained: “Further exploration and discussion of events takes place at monthly clinical governance meetings in which senior managers and clinical managers (medical and nursing) review our systems and learn from any issues raised.” More systemic issues are fed into the company via its online safety management system, he added.
Germany’s DRF Luftrettung also uses a reporting system for logistical issues, said Stefanie Kapp: “[For issues] regarding landing fees, costs and quality of handling agents and hotels, as well as [other] special aspects, we created a report sheet, which is filled out by the flight crew and is handed over to operation centre personnel when returning to home base. This data will be entered in our Alert Center Management System (ACMS) database and will be used as a reference for upcoming missions.”
At DRF Luftrettung, the debrief is affected by location and time of day. Kapp explained: “In general, the guideline for the briefing as well as for the debriefing is our mission report. This report is customised to our needs by our in-house IT department via our ACMS.” However, there are two typical debrief formats. At home base, debriefing normally starts around 30 minutes after landing: “Members of the debriefing are the medical crew, flight crew and one person from the operation centre on duty and who was responsible for the performed flight. Typical aspects are:
time schedule, used airports, permissions, refuelling processes, co-ordination of patient transport and/or pick-up of medical crew, and quality of provided medical information in relation to patient’s actual condition.”
Away from home base, the debrief is held in the hotel with flight and medical crew. Kapp continued: “If there are relevant points to be transferred to the operation centre, it will be either recorded on the written report, or immediately given via phone.” However, if it’s late in the evening, said Kapp, the debriefing can be delayed until breakfast the following day.
The question of who is involved in a debrief may be affected by what needs to be discussed. Tiba told ITIJ that where something has gone awry during a mission, the debrief should cover both logistical and medical aspects: “We would aim to find the root cause and establish a barrier / plan of actions so that it does not happen again.”
One challenge is for the provider to foster an environment in which problems can be openly discussed in order to harness learning opportunities. AirCARE1 utilises a debriefing structure that focuses on improving processes. A good debriefing structure is one where everyone feels valued and that their opinion will be heard, said Waye. “This includes using positive feedback in front of everyone and negative feedback on a one-on-one basis.”
The ‘Just Culture’ concept plays an important role here. David Quayle commented: “For a true reflection of events to be discussed openly and with candour, it is vital that the organisation has ‘Just Culture’ at its heart. Fear of punishment for speaking out or revealing errors, even where they were created through systems of work, inhibits staff from speaking frankly about events.”
The practice of routine debriefing is not universal
The practice of routine debriefing is not universal. For example, Airlec Air Espace of France only conducts a post-flight debrief after a complex mission, at the request of crew members who want to communicate something; for new pilots, for example, or if something went wrong, explained Paul Tiba. Having said that, whether a post-flight debrief is held or not, the provider’s medical director reviews every case. Tiba also highlighted the role of the pre-flight briefing, which the provider does hold for every flight: “Much more important than mission debrief is our mandatory mission briefing … with the whole crew (pilots and medical crew). It is important that all the crew has the same level of information before all missions.”
And while the three main accrediting bodies, CAMTS, NAAMTA and EURAMI, all call for debriefings in their standards, only CAMTS says a debrief should follow every mission: “A post-transport debrief is conducted after each transport that includes the communications specialist when communications issues are involved.” Both NAAMTA and EURAMI allow providers to use their discretion with regards to the regularity of such meetings, with NAAMTA simply stating that an organisation should have ‘a policy’ for post-flight briefings, and EURAMI saying that ‘proper and adequate debriefing of flight medical teams’ should be provided.
Waye said that mission debriefs are an important component of the organisation’s operations. She is clear in her belief that post-flight briefings can help a provider to continually improve the quality of its services. She stated: “Our company is successful due to the fact we have learned from the mistakes we have made.”
Debrief and improve
Whether they are done as a mandatory part of the post-flight routine or on an as-needed basis, the benefits of detailed debriefing meetings seem clear. For the operations and flight crews, they can ensure seamless and cohesive departures, many of which are time critical in the air ambulance sector. For the medical crew who have dealt with a particularly complex patient, the opportunity to consider what equipment was lacking – or taken needlessly, for that matter – or where a patient’s care could be improved for the next flight, offers a chance for improvement that can only benefit clients going forward.