Date of Doctor of Nursing Practice Project Completion

2026

Faculty Advisor

Shannon Warren, DNP, MBA, APRN, AGACNP-BC, TCRN, CCRN, CVRN-BC, CSC, CMC

Abstract

Purpose

This scholarly project aimed to implement an Acute Critical Event Debriefing (ACED) program in an intensive care unit to improve resuscitation quality by increasing post–cardiopulmonary arrest debriefing completion rates and enhancing documentation of airway confirmation during resuscitation events. The project took place in a 12-bed intensive care unit at a large academic safety-net hospital in Dallas, Texas.

Background

Structured debriefing after cardiopulmonary arrest events was recommended to enhance team performance, clinical education, and resuscitation quality. However, debriefing following code events was inconsistently conducted across many intensive care units, limiting opportunities for team reflection and quality improvement.

Methodology

The Plan-Do-Study-Act (PDSA) methodology guided targeted in-service training, including an introduction to the ACED program with visual aids, participation in mock codes to reinforce resuscitation practices, and hands-on training on airway confirmation documentation. Revisions were informed by debriefing rates, documented airway confirmations, and stakeholder feedback throughout the PDSA cycles.

Results

During pre-implementation, debriefing completion rates averaged 54%, well below the 80% target. After ACED implementation, rates increased to 63%, with one month reaching 100%, though variability remained. Documentation of airway confirmation improved from 0% pre-implementation to 100% during implementation, surpassing the target. Stakeholder feedback highlighted three themes: training value, desires for broader access and equity, and workflow and cultural barriers to debriefing.

Implications

The implementation of the ACED program was linked to improved resuscitation quality metrics, including a significant increase in airway confirmation documentation and modest rises in debriefing completion. Addressing workflow and cultural barriers may further boost sustainability and interdisciplinary participation in structured post–event debriefings.

Keywords

critical event debriefing, cardiopulmonary arrest, quality improvement

Share

COinS
 
 

To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.