Increasing Post-Code-Event Debrief Adherence in the Neonatal Intensive Care Unit: A Quality Improvement Project

Background: The neonatal resuscitation program (NRP) includes a complex, step-by-step algorithm that provides a pathway for resuscitation based on a neonate’s status and response to intervention—reported error rates during neonatal resuscitation range between 15% and 50%. A standardized post-code-event debrief protocol can improve individual and team communication, improve patient safety outcomes, and reduce environmental and technical barriers to successful resuscitation.

Local Problem: The project site was a 116-bed level IV Neonatal Intensive Care Unit (NICU) in the southeast United States (U.S.). The purpose of the quality improvement project was to implement a standardized debrief process to improve the adherence rate to completing a formal debrief checklist after all qualifying code events in the NICU. The aim was to increase the number of completed post-code-event debriefs from 1.8% to > 50% by August 1, 2024.

Methods: The Model for Improvement (MFI) provided a framework for project implementation. Adherence rates were calculated by assessing the number of completed debrief checklists compared to the number of reported code events that qualified for a debrief.

Interventions: The project team developed an operational definition of what code events qualify for a debrief, assigned a role to initiate the debrief checklist via a QR code, and identified a team leader to lead the debrief.

Results: From May 1, 2024, to October 8, 2024, 47 code events were reported, and 24 debrief checklists were completed. Out of 24 debriefs, 18 met the operational definition of a code event. The average debrief adherence rate improved from 1.8% to 65%. With variations in adherence rates and the data not being normally distributed, a median adherence rate of 55% was analyzed.

Conclusion: Creating a formal debriefing process led to an increase in post-code-event debrief adherence. Debriefing allowed the code team to recognize errors and provided an opportunity to find targeted solutions to improve patient safety.