Clinical Review

How simulation can train, and refresh, physicians for critical OB events

OBG Manag. 2008 September;20(9):42-54

References

1. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007;109:1295-1300.

2. Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclampsia drills. Qual Saf Health Care. 2004;13(2):127-129.

3. Hope P, Breslin S, Lamont L, et al. Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy. Br J Obstet Gynaecol. 1998;105:1256-1261.

4. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol. 2004;103:1224-1228.

5. Crofts JF, Attilakos G, Read M, Sibanda T, Draycott TJ. Shoulder dystocia training using a new birth training mannequin. BJOG. 2005;112:997-999.

6. Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol. 2006;108:1477-1485.

7. Friedrich M. Practice makes perfect: risk free training with patient simulators. JAMA. 2002;288:2808-2812.

8. Pizzi L, Goldfarb N, Nash DB. Crew Resource Management and Its Application in Medicine. In Making Healthcare Safer: A Critical Analysis of Patient Safety Policies. Evidence Report/Technology Assessment # 43. AHRQ Publication No. 01-E058, July 2001. AHRQ. Rockville, MD. www.ahrq.gov/clinic/ptsafety/

9. Brown JP. Closing the communication loop: using readback/hearback to support patient safety. Jt Comm J Qual Saf. 2004;30:460-464.

10. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol. 2003;102:388-392.

11. Gardner R. Simulation and simulator technology in obstetrics: past, present and future. Expert Rev Obstet Gynecol. 2007;2:775-790.

12. Deering S, Brown J, Hodor J, Satin AJ. Simulation training and resident performance of singleton vaginal breech delivery. Obstet Gynecol. 2006;107:86-89.

13. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. There’s no such thing as “non-judgmental debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006;1(1):49-55.

14. Gaba DM, DeAnda A. A comprehensive anesthesia simulator environment: re-creating the operating room for research and training. Anesthesiology. 1988;69:387-394.

15. Deering S, Poggi S, Hodor J, Macedonia C, Satin AJ. Evaluation of residents’ delivery notes after a simulated shoulder dystocia. Obstet Gynecol. 2004;104:667-670.

16. Joint Commission on Accreditation of Healthcare Organizations. Sentinel event alert. 31 July 2004.

17. Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG. 2006;113:177-182.

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Managing eclampsia

Thompson’s study of eclampsia simulation drills² identified three major problems in handling this emergency:

difficulty summoning senior staff
multiple protocols for managing eclampsia, without a clear first-line anticonvulsant
significant time lost gathering items required to manage seizures.

Based on what was observed in simulations, Thompson recommended 1) creating so-called eclampsia boxes that contain all necessary equipment and 2) establishing a liaison with the pharmacy to ensure consistency in supplies of magnesium sulfate.

Shoulder dystocia

The 5th Report on Confidential Enquiries into Maternal Deaths in the United Kingdom found that, in 66% of neonatal deaths following shoulder dystocia, “different management could have reasonably been expected to have altered the outcome.”³

Using a standardized shoulder dystocia simulation, Deering and colleagues reported significantly higher scores for residents who were trained in the scenario, including in the timeliness of their intervention, performance of maneuvers, and overall performance.⁴

Crofts, Draycott, and various colleagues developed a training mannequin for hospital staff that included a force-monitoring system comprised of a strain gauge mounted on both clavicles. After training, they found a reduction in 1) head-to-body delivery duration and 2) maximum applied delivery force after training, although these reductions did not reach statistical significance.^5,6

Where do you begin?

Starting a simulation program can be challenging: Significant financial hurdles may exist, and teamwork and communication issues can be major barriers to yielding improvements in practice. What’s the first step?

Find backing. Garner support for your project ( TABLE 1 ). It’s imperative to involve administrative leadership early.⁷ One champion cannot sustain a program of this magnitude.

Assemble a multidisciplinary team. Include obstetricians, gynecologists, anesthesiologists, neonatologists, and other members of the perinatal or surgical team. All will be needed to create complex interdisciplinary drills or simulations.

Build consensus. Determine the scope, goals, and objectives of the project. Define measurable outcomes.

Outline a budget. Make a realistic assessment of the resources available to fund the curriculum you design.

TABLE 1

Opening questions about a simulation training program

How do you get started?
Garner support Build consensus Define outcomes Create a budget
What are the key components?
Skills inventory Necessary competencies Stated objectives Adult learning principles Performance measures Debriefing Feedback

Know how adults learn

A simulation designed to raise the skill level of professionals—be they residents, nurses, or attending physicians—must recognize the special characteristics of adult learners. Unlike school children, adult learners are self-directed; they bring real-life experience to the table, are motivated primarily by a need to know, have individual learning styles, and deserve to be treated with respect.

A simulation curriculum should incorporate so-called crew resource management skills—a style of open cockpit communication of proven worth in improving airline safety.⁸ Those crew skills should promote best practices in closed-loop communication (such as the readback/hearback system⁹), information sharing, assertiveness, adaptability, and leadership skills—all elements of successful simulation. Means of coordinating, allocating, and monitoring team resources should be built into the curriculum ( TABLE 1 ).

Find the time

A practical rule to follow when designing a simulation goes by the acronym ARRON—As Reasonably Realistic as Objectively Needed.¹⁰

The team leader should match the task to:

time allotted
baseline level of medical knowledge of the trainee (resident, nurse-midwife, experienced attending)
budget.

A major hurdle, especially in a community hospital, is to schedule sessions at a time when as many providers as possible can attend. Taking time off for training is particularly difficult for office-based providers; a workable schedule must take their needs into consideration—possibly with evening or weekend sessions.

Multiple nursing shifts may necessitate repeating a simulation several times. Consider having a so-called stand-down declared, in which all nonemergency cases are delayed (if hospital administration is amenable). Alternatively, the hospital may allot time for a simulation exercise during a slot for a weekly educational lecture or monthly department meeting.

What equipment is needed?

A community hospital can develop a simulation program that is focused on its educational and safety needs. For example, a broad range of birth simulators is available ( TABLE 2 ). The features and capabilities of each model vary with cost (we do not recommend any particular simulator). The ideal childbirth simulator has yet to be defined, but existing modalities can be adapted to meet specific needs of a target audience. A standard obstetric birthing pelvis equipped with an inflatable uterus for simulating uterine atony, for example, can be modified and made to bleed from the model’s cervical os to simulate postpartum hemorrhage.¹¹ Commercial models (mannequins) are not always necessary for OB simulation; task trainers (devices that allow repeated practice of individual skills) and standardized patients (persons trained to portray patient scenarios) can also be used.