In part 1 of this two-part column we described the basics of critical incident stress management and reviewed the literature on its efficacy (1). In this second part we briefly describe the steps for developing a critical incident stress management program for an emergency department.
Needs and resource assessment
Before developing a critical incident stress management program in your emergency department, you must ascertain whether it is warranted. Determining the need for a program may involve several steps—interviewing employees, reviewing past records and incidents, reviewing the literature, and employing a consultant trained in critical incident stress management to conduct a more formal needs assessment (2).
One important consideration is the size of the hospital and the volume of the emergency department. A hospital that treats fewer than 25,000 patients a year probably could not effectively maintain an independent team, given the small number of critical incidents likely to occur in such a setting. No empirically based guidelines are available, but if only one or two critical incidents occur per year, then a team devoted solely to serving the department seems unwarranted. In such cases, a critical incident stress management program might best be implemented as a collaborative effort among several emergency departments and other departments or among other departments throughout the hospital, with each providing resources and personnel.
Garnering administrative support
For a team to be successful, the initiative must be fully supported by both hospital and emergency department administrators. This support should be garnered while the needs assessment is being conducted or shortly thereafter. Such support includes administrative permission to use facilities for debriefings; commitment of material resources such as copy machines, refreshments, and training rooms; and permission to be flexible in scheduling to accommodate group interventions.
Financial support of the team is an important administrative decision. It consists primarily of three expenditure categories: training of the critical incident stress management team members, paying for employees' time while they attend group interventions, and paying for the services of mental health professionals when warranted.
Mitchell and Everly (2) have offered several suggestions for this phase of development, including use of consultants or experts familiar with critical incident stress management to give presentations to administration officers; provision of reading materials to familiarize administration with the structure, purpose, and benefits of traumatic stress management programs; and use of personal accounts, individual testimonials, survey data, monitoring data, or sample events as evidence of the need to initiate a stress management program. In addition, the proposal should be clear and organized and should include a reasonable operational budget that addresses the financial issues discussed above.
Before developing a team in your emergency department, determine whether other teams are already operating in the area. We suggest contacting the International Critical Incident Stress Foundation, Inc., a nonprofit organization (4785 Dorsey Hall Drive, Suite 102, Ellicott City, Maryland 21042; phone, 410-750-9600). Critical incident stress management programs have long been used by firefighters, emergency response personnel, and law enforcement officers, and their organizations may provide support to others that are developing programs. Much of the groundwork may already have been done, and close liaison with these teams is encouraged.
In our view, a collaborative, multisite regional team that uses volunteers from several hospitals has distinct advantages and should be considered regardless of the size of the emergency department. Collaboration with other emergency department teams that are already established also may be helpful and may allow newer teams to benefit from the experience of more seasoned members.
A collaborative regional team also may assist smaller emergency departments and allow several departments to absorb the costs and the burden of providing personnel for regional coverage. Having personnel from a variety of centers helps programs maintain the key precepts of not debriefing one's own coworkers, not having supervisors debrief their employees, and never having involved personnel conducting the debriefings.
Selection of team members is an important facet of the development of a critical incident stress management program. Because such programs generally rely on voluntary efforts, the commitment of the team members must be strong. Mitchell and Everly (2) suggested that team members should be drawn to service in the program because of their dedication and commitment to people who give so much to the community. A cadre of committed people who are willing to complete the requisite training, maintain continuing education requirements, and be available for interventions with limited notice is necessary.
As for the number of members, the team must be sufficiently staffed to respond adequately within 24 to 48 hours of an incident (3). On a regional team, each of the participating emergency departments should be represented with peer members and mental health professionals. Although the participation of representatives of the clergy—priests, pastoral counselors, and others—is encouraged, it is optional.
Peer members. For an emergency department team, both nursing staff and physicians should be recruited. If no physician peer leaders can be identified, then critical incident interventions with physicians should be conducted one-on-one with a mental health professional.
Mental health professionals. Mental health professionals can be psychologists, psychiatrists, social workers, or other qualified licensed counselors. Given the variability in the scope and theoretical orientation of mental health training, the team should address the goodness of fit and expertise of the mental health professionals. Both the team and prospective recipients of services should be comfortable with them.
All members of the team must receive formal training, whether they are peer members or mental health professionals. Several organizations provide training, including the International Critical Incident Stress Foundation and the American Red Cross, but training also may be conducted by local professionals formally trained in critical incident stress management. When considering local professionals as potential trainers or consultants, it is important to interview them to determine the extent of their knowledge and experience with formal critical incident stress management training and operations. Thorough training of a team is estimated to cost about $6,000 (2).
Structure of the team. Although teams vary tremendously in their structure, every team must have a team coordinator. For an emergency department program, the team coordinator should be a health care professional who works in or closely with the department. Typically this role is filled by a registered nurse or a physician, but it can also be filled by a mental health professional. The team's clinical director should be a mental health professional. The clinical director supervises the team's training and continuing education and coordinates mental health support for defusings and debriefings.
Communications system. The program must implement a standardized communication system designed to enable any member of the emergency department to contact a member of the team—particularly the team coordinator—to request intervention services. A team communication system designed so that each member can be contacted rapidly should also be implemented.
Routine training and updates
Continuing education and training should be offered to all members routinely. The educational component of a critical incident stress management team can prevent deterioration of the members' skills and keep the team prepared for interventions despite the low frequency of traumatic events (4).
Record keeping and utilization review
Although tracking specific people involved in incidents is discouraged, it is good for a program to keep track of the services it provides through general, nonspecific records. The team should maintain records of training, education, and member involvement. Records of incidents and interventions should be sufficiently vague to protect the confidentiality of the individuals involved.
The development of a critical incident stress management program in an emergency department takes considerable time and commitment. Success depends on there being at least one truly dedicated individual to act as the team coordinator along with a core of at least three or four active, committed group members. This core group, which should include at least one qualified mental health professional, should eventually become associated with the program throughout the emergency department, the hospital, and, possibly, the community.
Although developing a critical incident stress management program is a difficult task, assisting those who have dedicated their lives to assisting others in times of crisis is a worthwhile endeavor. Such programs can prevent much suffering and disability among emergency department personnel.
Mr. McCabe is a graduate student in the department of psychology at Louisiana State University, and Dr. Boudreaux is with the emergency medicine residency program of the university's School of Medicine. Send correspondence to Dr. Boudreaux at the Emergency Medicine Residency Program, Earl K. Long Medical Center, 5825 Airline Highway, Baton Rouge, Louisiana 70805 (e-mail, firstname.lastname@example.org). Douglas H. Hughes, M.D., is editor of this column.