1. Dallas 2015 TFQO: Robert Greif EVREVs: Dana Edelson, COI #334 Robert Greif, COI #344 Taskforce: EIT EIT 645: Debriefing of resuscitation performance

2. Dallas 2015 COI Disclosure (specific to this systematic review) Commercial/industry Edelson: Laerdal Medical AS - Research support Greif: None Potential intellectual conflicts Edelson: Author on one of two included studies Greif: None

3. Dallas 2015 2010 CoSTR Briefings and debriefings NRP-033A,NRP-033B,EIT- 001A,EIT-001B Consensus on science Evidence from one prospective randomised controlled study (LOE 1169) and 17 other studies (LOE 3–4) of briefings and debriefings document improvement in the acquisition of content knowledge, technical skills, or behavioral skills required for effective and safe resuscitation. Only a single study (LOE 4170) revealed no effect of briefing/debriefing on performance, and no studies indicated that the use of briefings and debriefings had any negative effects. Treatment recommendations It is reasonable to recommend the use of briefings and debriefings during learning activities while caring for simulated patients and during clinical activities.

4. Dallas 2015 C2015 PICO Population: rescuers who are caring for patients in cardiac arrest in any setting Intervention: briefing or debriefing Comparison: no briefing or debriefing Outcomes: Critical 8: Survival Critical 7: Skill performance in actual resuscitations Important 6: Quality of resuscitation Important 4: Cognitive knowledge

5. Dallas 2015 C2015 PICO Population: rescuers who are caring for patients in cardiac arrest in any setting Intervention: briefing or debriefing Comparison: no briefing or debriefing Outcomes: Critical 9: Neurologically favourable survival Critical 8: Survival Critical 8: ROSC Critical 7: Skill performance in actual resuscitations Important 6: Quality of resuscitation Important 4: Cognitive knowledge

6. Dallas 2015 Proposed TR We recommend data-driven, performance-focused debriefing of rescuers following in-hospital cardiac arrest in both adults and children (strong recommendation/low quality of evidence). We suggest data-driven, performance-focused debriefing of rescuers following out-of-hospital cardiac arrest in both adults and children (weak recommendation/very low quality of evidence). Values and Preferences: In making the discordant recommendation for IHCA, we have placed a high value on the consistency and precision of the improvement in CPR quality and short term survival as the proximal endpoints of the educational intervention. We have placed a lesser value on the potential costs of implementation.

7. Dallas 2015 Search strategy

8. Dallas 2015 Inclusion/Exclusion Search results: 1061 939 in 2/2014 + 122 in 1/2015 Exclusion: 1059 Not debriefing (n=1052) This included emotional debriefing of events that did not include objective data and a focus on performance improvement Simulation debriefing (n=4) Morgan,2009,531(RCT); Savoldelli,2006,279(RCT); Dine, 2008,2817; Husebo,2012,23 Control group received debriefing (n=3) Carbine,2000,654; Cheng,2010,1664; Nadler,2011,163 Inclusion: 2 Definition: Requires objective data (i.e. not emotional debriefing), facilitator, and active participation of learners

9. Dallas 2015 Non-RCT bias asssesment StudyYearDesign Total Patients Population Industry Funding Eligibility Criteria Exposure/Outc ome Confounding Follow up Edelson, 2008, 1063 2008 Non-RCT 224Adult IHCAPartlyLow Wolfe, 2014,1688 2014 Non-RCT 120Peds IHCANoLow Summary of Bias Description of debriefing intervention Facilitated for multidisciplinary participation of team members Supplemented real-time automated feedback during CPR Utilized data from CPR sensing defibrillators Augmented with additional available data (eg resuscitation records, EMR and/or bedside monitor data) Timing: Edelson – Weekly, 45 min sessions Wolfe - Held within 3 weeks of an event

10. Dallas 2015 Forest plots: Clinical Outcomes Neurologically Favorable Survival Survival to discharge ROSC

11. Dallas 2015 Forest plots: CPR quality Compression Depth Compression Rate

12. Dallas 2015 Evidence profile table: IHCA

13. Dallas 2015 Evidence profile table: OHCA

14. Dallas 2015 Proposed CoS There were no RCTs and no studies isolating briefing. Data from two in-hospital observational before-after studies, one in adults (Edelson, 2008, 1063) and one in pediatrics (Wolfe, 2014, 1688) involving a total 318 patients and 2,494 epochs of chest compressions demonstrate improved outcomes following implementation of a data-driven, performance-focused debriefing program for resuscitation team members using CPR-quality defibrillator transcripts.

15. Dallas 2015 Proposed CoS (cont) For the critical outcome of “survival with favorable neurological outcome at discharge” in IHCA, very low quality data (downgraded for imprecision) demonstrated an improvement with debriefing from 28.8% to 50.0% [RR 1.73 (1.04 to 2.43)] For the critical outcome of “survival to hospital discharge,” very low quality of evidence data (downgraded for inconsistency) yielded an insignificant improvement from 17% to 18.8% (RR 1.35 (0.81 to 2.1)]. For the critical outcome of “return of spontaneous circulation” low quality evidence correlated the intervention with an increase of 54.7% to 66.5% (RR 1.25 (1.06 to 1.41)].

16. Dallas 2015 Proposed CoS (cont) For the critical outcomes of compression depth and compression rate within target range, moderate quality data (upgraded for strong association) demonstrated an improvement for both [RR 1.18 (1.15 to 1.21) and RR 1.25 (1.21 to 1.29), respectively]. For these same outcomes in the out-of-hospital setting, the quality of evidence was further downgraded for indirectness.

17. Dallas 2015 Proposed TR We recommend data-driven, performance-focused debriefing of rescuers following in-hospital cardiac arrest in both adults and children (strong recommendation/low quality of evidence). We suggest data-driven, performance-focused debriefing of rescuers following out-of-hospital cardiac arrest in both adults and children (weak recommendation/very low quality of evidence). Values and Preferences: In making the discordant recommendation for IHCA, we have placed a high value on the consistency and precision of the improvement in CPR quality and short term survival as the proximal endpoints of the educational intervention. We have placed a lesser value on the potential costs of implementation.

18. Dallas 2015 Knowledge Gaps Benefit for OHCA Benefit of briefing The ideal format in which to debrief: Source of objective data E.g. CPR-quality transcript, video, etc Duration of debriefing Interval of time between event and debrief