Optimizing Obstetric Care: Simulation-Based Training Strategies

1. Simulation Based Training: Are You Ready? Julie Arafeh MSN, RN

2. Julie Arafeh has no disclosures to announce

3. Objectives • Define the components of simulation based training • Review how simulation can be used in obstetrics • Describe how obstetric units have used simulation to improve patient care

4. Your Last Obstetrical Crisis:

5. How can simulation play a role in improving team response?

6. What is simulation based training? • An educational methodology NOT technology • Realistic team practice for application of cognitive and technical skills • Opportunity to observe and learn about team (behavioral) skills

7. Simulation Based Training • Scenario based • Designed to challenge & instruct • We DO NOT expect a perfect performance • Rare opportunity to see your practice on videotape

8. Components of simulation based training • Research to determine topic of training • Develop measurable learning objectives for all learners • Write scenario that supports learning objectives • Plan for debriefing

9. Debriefing • Facilitated discussion not a lecture • Where the learning from simulation occurs • Based on learning objectives • Covers incorrect actions • Long complex healthcare scenarios are more difficult to debrief

10. What can we learn about simulation based training from other industries?

11. High Functioning Teams:Aerospace Industry • "black box" revelations • 2/3 of disasters due to poor communication • response: Crew Resource Management (CRM) • cognitive, technical and behavioral skills • high fidelity training environment • annual training mandated by FAA Helmreich R, et al. Cockpit Resource Management. 1993.

12. Translated to Obstetric Practice…..

13. BJOG 2006 Feb;113(2):177-82 • Retrospective cohort obs study • Tertiary referral hospital • 5 min APGAR score and incidence of HIE compared pre and post simulation training • Significant reduction in low 5 min APGAR scores and HIE

14. Obstet Gynecol 2008;112:14-20. • Retrospective observational study shoulder dystocia mgment, neo injury • Mgment and neo injuries pre and post simulation training • Use of maneuvers for shoulder dystocia increased, significant reduction in neonatal injury

15. Joint Commission J Qual Patient Safety Aug 2011;37(8):357-64 • 3 small size community hospitals • Comprehensive interdisciplinary team training using in-situ simulation • Weighted Adverse Outcome score and Safety Attitudes Questionnaire • Persistent 37% improvement in perinatal morbidity

16. J Healthc Qual, Jan/Feb 2012;34(1):6-15 • Large tertiary medical center • Comprehensive perinatal safety initiative • Mod Adv Outcome Index  from 2% to 0.8% and was sustained • Improvements in staff preception of safety, pt perception of teamwork, mgment abnl EFM and hemorrhage

17. Return on Investment • Interdisciplinary OB simulation program started with seed money from risk management • After 6 + years lawsuits and claims decreased • Return on investment calculated > 300% Publication pending

18. Simulation Based Training to Impact Patient Care

19. System barriers to evidence based practice • Establish evidence based policies, procedures, guidelines • In-situ simulation run to see where barriers are to implementing evidence based care • Address system issues before staff education and wide-spread implentation

20. Rare event preparation • Simulation to prepare for rare events • Train staff on procedure • Uncover and address system issues • Further refine patient management plan • Anticipate complications and solutions

21. Targeted training • Selected group (code team) • 15 minute training session at beginning of day and night shift • Goals: • Introduce team members • Review role of each team member • Resuscitation drill with feedback based on AHA guidelines

22. Orientation to hospital • Series of simulations for new staff that review key tasks • Admission, transfer • Preparation for surgery • Blood administration • Wound care • RRT JONA 2010;40(10):424-31

23. Determination of best unit practice • Staff participated in stat CS in situ drill • Time from beginning of drill to time in room measured • Video of staff with best times examined • Best practice determined, disseminated to staff

24. Sentinel event review • In situ drill of staff involved in event • Clinical record also used to guide scenario • Goal: • Determine what circumstances led to event • Address issues to prevent repetition of above circomstances

25. Preparation for opening patient care area • Simulation depicting every day scenarios to uncover system barriers • Uncover any physical changes that need to be made • Prepare staff to use equipment, become familiar with space • Practice emergency response

26. Interdisciplinary training • Staff training for a particular diagnosis • Ideal time to include learning objectives for behavioral skills • Communication • Role delegation • Leadership

27. Research – Knowledge deficit • Study that launched research series • Cohen, Andes, Carvalho Assessment of knowledge regarding CPR of pregnant women • Anes, OB and EM staff tested; 25-40% questions for preg specific interventions answered incorrectly Int J Obstet Anes 2008;17:20-25

28. Research – Analysis of performance • 18 interdisciplinary OB teams eval in unrehearsed unannounced OB code • Proper compressions and ventilations delivered in slightly more than 50% • Pregnancy specific interventions frequently neglected Am J Obstet Gynecol 2010;203:179.e1-5

29. Research - RCT • Labor Room Setting Compared With the Operating Room for Simulated Perimortem Cesarean Delivery • 15 interdisciplinary teams randomized to deliver in LDR vs OR • Significantly faster in LDR Obstet Gynecol 2011;118:1090-4.

30. Publication – Life Support Simulation Program • Combination of BLS, ACLS, NRP • Interdisciplinary staff that work together on L&D • On-line programs completed before simulation day • Mega code – combined maternal/neonatal arrest JPNN 2012;26(2):126-35.

31. Research • Compare quality of chest compressions and ventilation stationary vs during transport • “…data confirm our hypothesis and demonstrate that transport negatively affects the overall quality of resuscitation on a mannequin during simulated maternal arrest.” Anesth Analg 2013;116:162-7

32. “These findings, together with previously published data on transport-related delays when moving from the labor room to the operating room further strengthen recommendations that perimortem cesarean delivery should be performed at the site of maternal cardiac arrest. “ Anesth Analg 2013;116:162-7

33. Consensus Statement • Anesth Analg 2014;118:1003-16 • The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy

34. Consensus Statement • SOAP statement • “…improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest.”

35. Preparation for Simulation Based Training

36. Preparation • Determine what kind of simulation needed/impact on patient care • Instructors attend/have attended a simulation instructor training program • Time designated for developing simulation

37. Logistics • Staff attendance supported • Location (sim center or in situ) • Number and mix of learners should mimic response needed to manage scenario • For entire unit training, determine how many simulation sessions needed

38. Learner preparation • Give learners information about cognitive skills needed • Technical skill practice before scenario supports muscle memory and familiarizes learners with simulation equipment

39. Record It! • Record/audio video • No disputes about actual event • Analysis for research, metrics • Visualization of positive behavior, areas for improvement

40. Changing Culture: The Circle of Safety Analysis of training/ Correction of issues Care of real patients Risk Management, Quality Assurance data Simulation training

41. Mannequin Manufacturers • Simulaidswww.simulaids.com • Laerdalwww.laerdal.com • METI www.meti.com • Gaumardwww.gaumard.com • Limbs and things www.golimbs.com

42. References • Riley W et al. Didactic and Simulation Nontechnical Skills Team Training to Improve Perinatal Patient Outcomes in a Community Hospital. Joint Commission J Qual Patient Safety Aug 2011; 37(8): 357-364. • Boston-Fleischhauer C. Enhancing Healthcare Process Design with Human Factors Engineering and Reliability Science, JONA 38(1) pp 27-32. • Andreatta P et al. Interdisciplinary team training identifies discrepancies in institutional policies and practices. AJOG 2011 Oct;205(4):298-301.

43. References • Weaver SJ et al. Twelve best practices for team training evaluation in health care. Jt Comm J Qual Patient Saf 2011 Aug;37(8):341-9. •  Hansen SS et al. Implementing and sustaining in situ drills to improve multidisciplinary health care training. JOGNN 2012;41(4):559-70 • Buljac-Samardzic M et al. Interventions to improve team effectiveness: a systematic review. Health Policy 2010 Mar;94(3):183-95 • Riley W et al. Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies. Qual Saf Health Care 2010 Oct;19 Suppl 3:i53-6

44. jarafeh@stanford.edu