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Mobile In Situ Obstetric Emergency Simulation and Teamwork Training to Improve Maternal-Fetal Safety in Hospitals
The Joint Commission Journal on Quality and Patient Safety Human Factors Engineering
Mobile In Situ Obstetric Emergency Simulation and Teamwork Training to Improve Maternal-Fetal Safety in Hospitals Jeanne-Marie Guise, M.D., M.P.H.; Nancy K. Lowe, Ph.D., C.N.M.; Shad Deering, M.D.; Patricia O. Lewis; Christen O’Haire, Ph.D.; Lori K. Irwin, R.N., M.S.; Molly Blaser, R.N., M.S.; Laurie S. Wood, M.S., R.N., C.N.A.-B.C.; Barbara G. Kanki, Ph.D.
C
hildbirth is the most common reason for admission to the hospital for women, with more than 4 million children born each year at approximately 6,000 hospitals in the United States.1,2 Obstetric emergencies can present in otherwise healthy, low-risk women at term, complicating up to 15% of all births.3 Emergencies such as amniotic fluid embolism (AFE) occur rarely (estimated at one in 8,000–30,000 pregnancies), yet the consequences can be profound. More than half of women who suffer an AFE die within the first hour after symptoms present.4 Efficient recognition and appropriate response by clinical teams are critical; however, given the rarity of such obstetric complications, decades can pass before a health care worker would see a case, making it challenging for teams to remain confident, competent, and efficient in responding. Communication issues also compound the challenge of responding to infrequently occurring emergencies. The Joint Commission5 and other international organizations6–8 consistently report that communication failures and lack of teamwork are major contributors to adverse obstetric outcomes. The Joint Commission reported that human factors issues such as communication were attributable for 2/3 of sentinel neonatal events.5 Similarly, a confidential inquiry in England found that suboptimal care was associated with 75% of stillbirths.6 In addition, lack of teamwork and poor communication have been found to be significant contributors to malpractice claims and have been estimated to be associated with as many as onethird of closed obstetric malpractice cases.9 One report found that teamwork and communication problems were accountable for 71% of closed claims that involved medical residents or fellows, suggesting that the problem may be more extensive in training institutions.10 Yet, traditional clinical training does not provide education on communication strategies and teamwork. After discovering nearly 40 years ago that human factors issues such as communication and teamwork were responsible for 60%–80% of plane crashes, the aviation community
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Article-at-a-Glance Background: Evidence from other high-risk industries
has demonstrated that teamwork skills can be taught and effective teamwork may improve safety. Increasingly, health care providers, hospital administrators, and quality and safety professionals are considering simulation as a strategy to improve quality and patient safety. Mobile Obstetric Simulation and Team Training Program: A mobile obstetric emergency simulation and team training program was created to bring simulation technology and teamwork training used routinely in other high reliability fields directly to health care institutions. A mobile unit constituted a practical approach, given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites. Between 2007 and 2009, in situ simulation of obstetric emergencies and teamwork training was tested with more than 150 health care professionals in labor and delivery units across four rural and two community hospitals in Oregon. How Do Organizations Determine Which Type of Simulation Is Best for Them? Because simulation technologies are relatively costly to start and maintain, it can be challenging for hospitals and health care professionals to determine which format (send staff to a simulation center, develop in-house simulation program, develop a consortium of hospitals that run a simulation program, or use a mobile simulation program) is best for them. Conclusions: In situ simulation is an effective way to develop new skills, to maintain infrequently used clinical skills even among experienced clinical teams, and to uncover and address latent safety threats in the clinical setting.
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The Joint Commission Journal on Quality and Patient Safety embraced crew resource management (CRM) and simulation to train aviation teams in teamwork and to provide them with a venue to practice essential teamwork skills.11 The development of routine simulation and teamwork training in aviation exercises may have been a primary contributor to the dramatic reduction in fatal plane crashes in the past several decades.12–14 Increasingly, clinicians, hospital administrators, and quality and safety professionals are considering simulation as a strategy to improve health care quality and patient safety. Numerous studies have demonstrated the realism and educational value of simulation in medical training.15–17 In addition, several studies have examined simulation as a mechanism to transmit and improve the retention of knowledge and technical skills.18-26 However, few studies have evaluated simulation as a method to improve obstetric emergency response and safety for clinical teams.3,27–30 Thomas et al., who observed teamwork during neonatal resuscitations in the delivery room, found that most teamwork skills can be reliably evaluated.22,31,32 They also identified three main factors that were associated with good teamwork: communication, management of work load/resources, and leadership. Draycott et al. have also conducted several interesting studies relating to simulation and obstetric safety.33–36 In one of these studies, they reported a significant decrease in the rate of hypoxic ischemic encephalopathy from 27.3/10,000 before simulation training to 13.6/10,000.36 This emerging evidence suggests that simulation can play an important role in improving health care delivery and health outcomes. Importantly, very little is known about the value of and considerations for in situ (in the clinical setting) simulations across practice settings, particularly in the high-risk field of maternity care. We developed a mobile obstetric emergency simulation and team training program to examine whether there was value for in situ simulation for experienced clinical teams from rural and community hospitals in Oregon. Given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites, the creation of the mobile unit was a practical approach. Oregon has been one of the crisis states for obstetric care, with one survey conducted in late 2002, for example, indicating that one-third of maternity providers, of whom 66% were rural care providers, planned to stop delivering babies in the subsequent one to five years.37 The reasons cited by providers for ceasing to provide obstetric services included liability insurance costs, fear of lawsuits, low patient volume, and concern for 444
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skill level. Rural hospitals are particularly strained, given that they are required, through the Emergency Medical Treatment and Active Labor Act (EMTALA), to provide emergency services for delivering or laboring pregnant women.38 Yet they have limited resources, few skilled maternity providers, and infrequent hands-on experience with such emergencies. Considering these obstacles, we focused the mobile obstetric emergency simulation and team training program on rural and community hospitals, with the thought that access to training opportunities may be particularly limited. In this article, we describe the process of developing an emergency simulation curriculum, discuss the advantages of in situ simulation, and share lessons learned and describe patient safety improvements that can result from conducting in situ simulation training.
Mobile Obstetric Simulation and Team Training Program BACKGROUND In 2005 we partnered with the founders of CRM at the National Aeronautics and Space Administration (NASA) and experts in skills-based simulation through a grant from the U.S. Agency for Healthcare Research and Quality to develop a selfcontained mobile obstetric simulation and team training program. The goal of the program was to bring simulation technology and teamwork training that is used routinely in other high-reliability fields directly to health care institutions to improve the processes of obstetric care and to promote safety. This goal was based on the operating principles shown in Table 1 (page 445). Furthermore, the intent of the curriculum was to “transform good teams into extraordinary teams” through teamwork training and practice responding to infrequent obstetric events to ultimately improve outcomes for mothers and babies. Between 2006 and 2008, we conducted testing with more than 150 health care professionals to determine whether in situ simulation of obstetric emergencies and teamwork training could improve the process of care and patient safety in labor and delivery (L&D) units across six different hospital settings in Oregon—four rural and two community hospitals—with 45 to more than 1,600 deliveries a year.
RECRUITMENT Hospitals were purposively selected for geographic, hospital, and practice diversity. Initial visits were conducted presenting the program to hospital, practice, and nursing leadership, and participation agreements were signed. All hospitals approached
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The Joint Commission Journal on Quality and Patient Safety Table 1. Operating Principles 1. Physicians, nurses, and other health care staff are well-trained, knowledgeable experts in their fields who are deeply dedicated to providing high-quality patient care. 2. Obstetric emergencies occur infrequently, and practice may support clinician’s confidence and efficiency in responding. 3. Interdisciplinary teams whose members respond together should train together. 4. In situ simulation in the familiar clinical setting is the best way to improve safety and activate team members to learn and practice best-evidence team skills. 5. Adult learners learn and retain skills well through practice.
agreed to participate in both an initial simulation and team training and a follow-up simulation visit to measure retention and adaptation of skills.
OUTLINING
THE
EDUCATIONAL SESSION
We outlined the educational session as follows: 1. Introduction to simulation, with the opportunity to conduct a simulated normal vaginal birth 2. Emergency simulation scenario no. 1 3. Facilitated team debriefing, followed by a standardized clinical didactic focused on the specific emergency of the first simulation and a standardized teamwork skills didactic 4. Emergency simulation scenario no. 2 5. Facilitated team debriefing followed by a standardized clinical didactic focused on the specific emergency of the second simulation
DEVELOPING A MEANINGFUL CURRICULUM Engaging Stakeholders in Development. In developing the program, we—as members of the interdisciplinary team— spoke with hospital leaders around the state, who stated that they were dedicated to patient safety but echoed a practical reality that was well described by one CEO: “Our staff are time constrained and it is hard to get them away from patient care to improve their patient care.” This meant that the curriculum needed to be short, engaging, accessible, and clinically important and have a high perceived return on investment. Meeting the Needs of the Whole Team Through an Interdisciplinary Development Process. Curriculum development began by focusing on clinically important topics pertinent to interdisciplinary clinical teams. In general, we chose to simulate obstetric emergencies, such as shoulder dystocia, postpartum hemorrhage, and eclampsia, because their time-critical nature makes communication and teamwork issues apparent,
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their emotional charge and impact activate experiential learning, and their infrequent nature and high stakes make them ideal for repetition through simulation. When running interdisciplinary simulations for clinical teams, it is important for the simulation to have face validity across the range of professionals with representative complexity and reasonable scenario difficulty for each role.39 Representatives from all disciplines that would respond clinically to a particular emergency worked together to develop each simulation scenario. This proved to be a tremendous asset, helping to ensure that the simulation scenario was valid to all clinical participants and included important elements for each participant. An alternative development approach is to have one person draft the initial scenario, circulate the draft among the team members for revision, and then further refine the scenario when it is used in simulation. The potential drawbacks to the latter approach is that it can be more time consuming, can be particularly draining on the individual creating the scenario, makes buy-in from other disciplines more difficult, and has a higher risk of poor scenario integrity, with inconsistencies or problems when the scenario runs in the interdisciplinary setting. We found that scenario development by a representative interdisciplinary group was efficient, promoted collegiality, increased buy-in across specialties, was enjoyable, and made us more aware of incorrect assumptions participants were likely to hold that may affect teamwork or clinical behaviors. Organized Approach. It is important for simulation development to use an organized approach. Following the case outline adapted from the Harvard Simulation Center by James Gordon, Brown, and Armstrong,24 our interdisciplinary team met to outline each scenario, develop primary and secondary learning objectives, and detail the technical requirements of the scenario (Figure 1, available in online article). In developing the scenarios, we determined what key findings, responses, or behaviors were expected from various team members. These key elements determined the length of the scenario by specifying endpoints, as well as the critical teaching points for the didactic. For example, depending on the desired key elements, we may have specified that a vaginal delivery ended with the birth of the baby or after a particular sequence in neonatal resuscitation. In addition, we set a time limit for each scenario that was observed even if all desired behaviors were not demonstrated. We also sought to protect participants by ensuring that no matter what happened, the mother or baby never died during simulation. Research in the aviation field has indicated that such traumatic simulation experiences can make participants fearful of ever stepping into the cockpit again, real or simulated.
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The Joint Commission Journal on Quality and Patient Safety Detailed Script. After we finalized the overall outline for the scenario and learning objectives, we wrote a detailed script for all confederate dialogue, technical requirements, and possible variations in flow of the simulation. We then verbally walked through the script, and, following any needed revisions, completed at least one run-through, with our team members playing the roles of participants. To finalize the script and technical requirements, we had interdisciplinary teams who were not involved in the curriculum development participate in the simulation to identify unanticipated behaviors or technical issues. Evidence-Based Clinical Didactics. In addition to the simulation scenarios, we developed an evidence-based clinical didactic specific to the clinical problem of each scenario. Each didactic was designed to be succinct and clinically relevant by focusing on issues that all L&D team members need to know. Our didactics did not cover the typical epidemiology and pathophysiology of the clinical problem but included the most common predisposing factors, presenting symptoms, treatments, and other clinically important considerations, such as what each medication looks like, dose and route of administration, how long it takes to administer, and so on. Interdisciplinary team members expert in conducting systematic reviews assisted in ensuring that all aspects of curriculum development followed an evidence-based process. The didactics were standardized as electronic video files, including a PowerPoint® presentation, instructional film vignettes, and voice-over by an instructor. Didactics, ranging from 4 to 14 minutes, were consistent with the complexity of the management of specific obstetric emergencies. Teamwork Skills. Despite the provision of the clinical didactics, the curriculum’s focus was the development of teamwork skills rather than the specific clinical skills unique to each simulation scenario. Therefore, each scenario had primary and secondary teamwork learning objectives, such as the following: ■ Using SBAR (Situation, Background, Assessment, Response) to orient team members as they arrive to the situation ■ Transparent thinking (thinking out loud) among team members ■ Directed and closed-loop communication (directing communication to a particular person either by using their name or visual cues and confirming receipt of the message) The companion teamwork didactic, which was designed to be interchangeable with any clinical topic, provided concise best practices in teamwork and was followed by video clips portraying how each skill could be used in obstetrics. For example, the didactic included an example of transparent thinking in an 446
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Table 2. Teamwork Didactic Content 1. Communication Orientation: Situation, Background, Assessment, Response (SBAR) Transparent thinking (thinking out loud) Directed communication Closed-loop communication 2. Situational Awareness/Resource Allocation/Backup Behaviors Call for help early Know all human and technological resources available and how to access them quickly Backup behaviors/cross-monitoring Avoid target fixation (tunnel vision) Situational awareness/performance monitoring Consider event manager 3. Role Clarity/Leadership 4. Decision Making and Cross-Monitoring Prioritize other responsibilities appropriately
obstetric emergency so a provider who typically is not comfortable thinking out loud can see how the skill might be done and potentially try it in the next simulation scenario. Topics covered in the teamwork didactic are outlined in Table 2 (above).
RESOURCES FOR CONTINUED LEARNING We intentionally kept our field didactics brief, focusing only on those things that everyone in the room needed to know. However, simulation can prompt participants to want to learn more about a given topic. For this purpose, we developed a teamwork training manual for distribution and also provided a book that contained greater depth of information on clinical topics.
TECHNICAL CONSIDERATIONS The curriculum was designed to be entirely self-contained so that participating institutions only needed to reserve one patient room and a second room to conduct private debriefings. Other than locally supplied delivery packs and linens, we brought all equipment and supplies necessary to run the scenarios and the debriefings (Table 3, page 447). Although we purchased the top-of-the-line obstetric simulator with all the technological capabilities of the time, we found that for mobile simulation it was optimal not to use many of the hightechnology (-tech) options. We found that response time was critical because clinicians expected responses to their maneuvers and interventions without substantial delay, similar to what they would see in real life. Rapid response times were difficult
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The Joint Commission Journal on Quality and Patient Safety Table 3. Mobile Simulation Equipment Simulation Equipment Gaumard Noelle S550™ obstetric simulator Advanced Medical Simulations FetalSim™ fetal heart rate simulator that connects to local fetal monitor Gaumard PEDI® Blue Neonate Extra parts and repair supplies for simulator in case of breakdown Dictaphone with recorded fetal heart sounds if needed Debriefing Equipment 19-inch television monitor Mini-digital video (DV) recorder with boom DVD video recorder with boom Other Equipment Scenario-specific kits (e.g., simulated medications, simulated blood, equipment) Mobile cart to transport equipment Cleaning supplies
to achieve using standard programming of the simulators available at the time. For example, in a shoulder-dystocia scenario using computer-guided delivery, if the participant wanted to perform a Zavanelli maneuver (replacement of the fetal head into the pelvis), the computer-controlled motor would reverse the direction rather slowly and create a constant force that is not typical of a live woman and fetus. Second, certain technical features of the high-tech equipment made it very hard for participants to suspend disbelief (an important contributor to the value of the simulation). For example, the motor that drives the baby down the abdomen in the simulation mother was very loud and made noises that no woman would make even in the most difficult labor. Third, the number and length of cords connected to the simulator mannequin limited our mobility and the maneuvers the participants could use. Because of this, we most often chose a low-tech approach to provide versatility. We created a harness for the baby that one of our staff (playing the role of labor support person) held to control the descent/ascent of the baby and respond to maneuvers used by the participant. We also created PowerPoint presentations for vital signs to enable us to change more quickly between vitals with and without oxygen saturations or to quickly respond to a request for another set of vital signs. In addition, we inserted audio onto the slides as indicated. For example, audio of a crying baby was inserted when resuscitation of the newborn was not a focus of the scenario and we wanted the team to attend to the mother. We created other simple low-tech solutions to simulate events, such as seizures that we wanted to control
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regardless of the position of the mannequin. We did feel, however, that investment in a separate fetal simulator was worthwhile because it allowed us to plug into any local fetal monitor so the fetal tracing and audio were similar to the participants’ normal clinical reality. In obstetrics, the constant background monitoring of the fetal heart sounds made this element important to engage participants in the simulation.
SCHEDULE AND CONSENT After all the pieces were developed, we planned a typical onsite schedule for how many teams we could accommodate for training per day, with the curriculum for each team requiring 2.5 hours. At the beginning of the in situ training, each participant was asked to sign a video consent to permit simulation videotaping required for debriefing and a confidentiality agreement to ensure that “what happens in simulation stays in simulation” and that participants out of professional respect hold in confidence their colleagues’ performances.
SPECIAL CONSIDERATIONS FOR IN SITU SIMULATION We visited every site before scheduling the on-site training to meet with hospital, nursing, and practice leaders. The purpose of this visit was to obtain buy-in, understand local team structure and care processes, identify key contacts who could schedule teams for the simulation curriculum and coordinate our technical needs during our visits, and to sign agreements. Conducting simulations in the location where care is delivered is convenient for staff and maximizes learning because the participants are in their familiar clinical environment. This approach is also useful to explore and analyze systems issues that affect care delivery during emergencies. However, there are unique issues that are important to consider when simulating in the clinical environment. We learned that we needed four to five staff members for each trip—including two clinicians trained in simulation debriefing, a registered nurse, a “voice” (someone who is behind the patient drape, at the head of the mannequin, and who also worked as a technician for the simulation mother), and a videographer. The two clinicians rotated between the instructor/debriefer role and a support person for the mother—a role that usually included conducting technical aspects of running the specific scenario. Another important consideration is medication safety. Companies sell simulated medications, blood, and so on, that look exactly like the real thing. However, just as in clinical care, it is possible that a participant could put a simulated medication in a pocket or other place that would directly affect patient care by making it possible for a simulated medication to be
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The Joint Commission Journal on Quality and Patient Safety given to a real patient. To eliminate this risk, we created simulated medications that were clearly labeled with drug name and dosage, in correctly sized dispensers for sufficient realism but also clearly identifiable as simulated medications (that is, visually distinct from real medications). This way, even if a simulated medication is left behind, it is obvious that it is not to be used clinically. Another consideration for in situ simulation is how participants normally access equipment or medications, where these items are normally located, and how they are acquired for bedside use. Because people commonly need to go to machines such as a Pyxis® (automated medication dispensing system) to obtain equipment or medications, we have a staff member act as a “human machine” outside the simulation room. If the nurse or other staff must go to a machine for a specific medication or item, our “human Pyxis” asks the participant for the information required for Pyxis entry and has the participant wait the amount of time it would take to walk from the room to the Pyxis and back again. Other local considerations include central monitoring that should be disabled for the simulation, code buttons or call light systems that should be covered or disconnected, locations of various equipment or other needs that will be simulated, and in-room sharps containers that need to be taped over so that simulated medications are not lost. We kept all our items organized according to scenario both for ease of set up and also to allow preparation of items from a checklist. Finally, taking simulation into the clinical setting required flexibility and ingenuity on the part of the simulation team to respond to local challenges. For example, the unpredictable nature of obstetrics sometimes resulted in L&D rooms being occupied by real patients when we were scheduled to conduct simulations. In these situations, we often used rooms considered overflow space. Although the participating institutions found this undesirable, in reality it offered the opportunity to test the physical plant and systems issues that often come up when patient census is high. We also adapted to high patient census through flexibility in the debriefing location. Debriefing can be effectively done in any room as long as there is privacy and enough room for the participants and debriefer to be comfortably seated facing each other. We have used empty patient rooms, consultation rooms, private staff lounges, and miscellaneous other hospital rooms for debriefing.
How Do Organizations Determine Which Simulation Format Is Best for Them? Human patient simulators are implemented in a number of 448
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clinical and educational settings with a variety of intentions. Table 4 (page 449) presents issues that organizations may want to consider when debating whether center-based simulation or in situ simulation is best for them. The goals of simulation conducted in situ may differ from simulation conducted in simulation centers. For example, simulation that is conducted in the clinical setting is uniquely connected to the clinical setting in which clinical care is provided, and so it is uniquely suited to identify systems issues and inefficient or incorrect responses among clinical teams. Simulation centers have the unique ability to have multiple high-tech simulation equipment setups, making this setting uniquely able to provide efficient instruction in technical skills acquisition and use simulation as a part of a larger didactic curriculum. Similarly, because in situ simulation requires purchase of only the simulation equipment itself, in situ simulation or mobile in situ simulation provides institutions with the opportunity to try simulation training before deciding to invest in the development and building of a simulation center.
Findings and Advantages of In Situ Simulation One of the most compelling reasons to conduct in situ simulation is the ability to identify latent quality and safety issues in the clinical environment while refreshing knowledge and clinical skills among clinical teams. As shown in Table 5 (page 450), consistent themes emerged among sites regarding latent quality and safety issues that were identified in conducting simulated obstetric emergencies in situ. The most common problem was inconsistent information on medications and knowledge about emergency medications such as those used to treat postpartum hemorrhage. Providers and staff often lacked knowledge about medication dosing, route of administration, and contraindications to medications that were not used frequently. Examples of behaviors observed during the emergency involving medications included administration of the most commonly used medication even when it was contraindicated for that patient, administration of medications through improper routes, and delays in administration caused by uncertainty for route of delivery. Solutions implemented by several hospitals included the development of emergency-specific (for example, obstetric hemorrhage) kits that contain all possible medications, equipment required to administer the medications, and a card containing accurate information of the medication route, dose, and contraindications. The kit served as a memory aid, but it also improved efficiency for obtaining medications in an emergency because all medications were now stored in one location.
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The Joint Commission Journal on Quality and Patient Safety Table 4. Comparison of Center-Based Simulation to In Situ Simulation Center-Based Simulation
Suggestions for In Situ Simulation
Elaborate Technology Possible ■ Highly sophisticated computers ■ One-way glass ■ Control station; simulation team communicates freely
Simple Technology Preferred ■ Low-tech computers simplify connectivity and technical difficulties ■ No physical barriers between participants and simulation personnel (with exception of sheet at head for live voice) ■ No control station; all personnel communicate in role
Convenience ■ Convenient for simulation personnel ■ Challenging for participants (travel, unfamiliar environment, and equipment) ■ Less likely that all personnel from the clinical settings could simultaneously participate (often individuals bring back lessons learned to local group) ■ May limit combined-team opportunities
Convenience ■ Challenging/inconvenient for simulation personnel (travel, unfamiliar environment/equipment, frequent set-ups) ■ Convenient and familiar to participants ■ Clinical teams can respond in simulations with their partners in the real clinical setting (promotes and reinforces group learning and adoption).
Scheduling ■ Need to arrange substantial time away from clinical activities for staff to attend ■ Reliably available at time when the simulation is scheduled ■ May offer expanded time for simulation and debriefing
Scheduling ■ Staff can participate while working (need to arrange cross-coverage for smaller times). ■ Less reliable scheduling because clinical volume may result in all rooms being full and need to reschedule ■ May be more time pressure for simulation and debriefing
Medication Safety & Clinical Equipment ■ Medications can appear identical to real medications (little risk for use in real life). ■ Use Center equipment, which may not match local clinical equipment
Medication Safety & Clinical Equipment ■ Simulated medications intentionally appear fake to prevent administration to real patients. ■ Can use familiar local medical equipment (e.g., units’ electronic fetal monitors) ■ Allows for immediate identification of some safety issues in own clinical environment
Debriefing ■ High-tech room (with computer/video overlays possible)
Debriefing ■ Can use any private room close to simulation ■ Video must include important visuals (not conducive to overlays).
Team Training Implications ■ Can teach teamwork principles ■ Able to mix classroom setting and simulated clinical setting ■ May be more challenging to transfer teamwork skills to clinical setting because of the following: –Limited personnel in attendance –Lack of familiar triggers to imprint into “muscle memory”
Team Training Implications ■ May be easier to transfer teamwork skills to clinical setting because of the following: –Actual clinical teams practicing and learning together –Familiar surroundings to trigger to imprint into “muscle memory”’ –Clinical setting may increase meaning and activate learning among participants
Another common issue involved stocking of the rooms, particularly checking emergency equipment, which was not commonly used. Several hospitals indicated there was either no clear person assigned to stock rooms, the nurse caring for the patient was supposed to restock rooms after a delivery, or a person was designated but there was no comprehensive list of items to be stocked. During simulation, it was commonly observed that nurses would need to leave their patient to obtain missing
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equipment. Even in hospitals where roles were assigned, items that were infrequently used, such as the emergency phone and resuscitation equipment were not available during the emergency—for example, laryngoscope pieces were missing or batteries for the laryngoscope did not work. Another common theme that the simulations uncovered at many institutions was inconsistent understandings of roles and expectations of individuals. This was most commonly discov-
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The Joint Commission Journal on Quality and Patient Safety Table 5. Quality Issues Identified and Improved Through Simulation* Quality Issues Identified A Environment/Room Stocking and Storage Room stocking (e.g., vacuum, respiratory therapy, IV equipment) inconsistent or did not have designated individual to stock room Stool in bathroom farthest from patient and often blocked Tracking Time Unaware of ability of fetal monitor to mark time Inconsistently marked time Clock out of nurse's line of vision Clinical Information Posters in room illustrate improper techniques (e.g., McRoberts technique)
B
Hospital C D
Solutions E
F
– –
+ –
– +
+ –
+ –
+ –
+ – –
– + –
– – –
– – +
– – –
– – –
–
–
–
–
+
+
+ +
+ –
+ –
+ –
+ –
+ –
– –
– +
– –
+ –
+ –
– –
–
+
–
–
–
–
– – –
+ + –
+ – +
+ – –
+ – +
+ – +
–
–
–
–
+
Staffing and Staff Roles Inconsistent expectations regarding identification and roles of helpers
+
–
+
–
–
+
Communication Hesitant to use transparent thinking (thinking out loud)
+
–
+
–
–
+
Knowledge of Protocols/Documentation Inconsistent knowledge of emergency protocols (e.g., massive transfusion)
–
–
+
–
–
–
Medications, Devices, and Equipment Medications Inconsistent or inaccurate information listed on medications Inconsistent knowledge of where all medications stored Difficulty obtaining medications because of multiple storage locations Unlabeled IV lines when several present Electronic Health Record Delayed documentation of key medical information until after emergency Balloon Tamponade No/inconsistent awareness of balloon tamponade device Inconsistent knowledge of where balloon stored No balloon available Miscellaneous Equipment Battery in emergency cordless phone did not work
* +, quality issue identified; –, quality of issue not identified; IV, intravenous.
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■ Designated stocking person and stocking routine/schedule ■ Ensured placement of equipment in room conducive to emergencies ■ Repeated simulations to test ■ Modified equipment storage based on use and easy access ■ Removal of out-of-date materials
■ Created emergency kits (e.g., postpartum hemorrhage kit) containing all related medications, syringes, and needles and taped card to kit with doses, route, and contraindications ■ Established alternative methods to obtain medication information (call the pharmacy, reference books, consultants) ■ Conducted periodic in-service on emergency equipment and medications and their storage locations and discussed expectations of stocking, including checking infrequently used emergency equipment ■ Ensured consistent labeling of IV lines ■ Standardized and communicated expectations regarding equipment and documentation of information ■ Standardized roles and expectations of helpers, including family ■ Developed examples of statements to use and practiced in simulations ■ Conducted in-services on protocol locations and how to use, practice in simulations
The Joint Commission Journal on Quality and Patient Safety ered during the debriefings of the simulation, when nurses, physicians, and midwives would discuss their impressions of what they thought they should do when called in to help, compared with the expectations of the person calling. Particularly in the case of the second nurse entering the scenario, participants mentioned not knowing what they should do and therefore waiting for instruction from the primary nurse, as well as having conflicting beliefs of the helper’s role. For example, one individual believed that the second nurse always is in charge of everything involving the second nurse’s side of the room (for example, if intravenous [IV] start supplies are on his or her side of the room, he or she starts the IV), or others believed that the second nurse is always the baby nurse. During simulation this contradictory vision of roles could be seen as inefficiency and at times caused confusion and delays. The debriefings, in which team members were brought together to talk about their experience and understandings, served as an ideal venue to problem solve mundane yet critical issues and misunderstandings efficiently. Because they were the ones uncovering the issues (through facilitated discussion) team members were engaged to find solutions and to try them out.
Discussion There is considerable controversy about the best use of simulation in clinical practice and training. Simulation, whether done locally, in simulation labs, or through mobile simulation, is expensive and resource intense. Thus, understanding the optimal use of simulation is critical. In our experience, in situ simulation offers the unique ability to probe the complexities of the clinical and interpersonal dynamics simultaneously. Conducting simulations in situ offers the unique and powerful opportunity to replicate real-life scenarios and to evaluate team and organizational performance. It also offers the greatest breadth of learning for experienced health care workers—it tests the physical environment and systems for safety, provides hands-on experience for clinicians regarding clinical conditions that are rare but reasonably likely to occur during their careers, and promotes reflection and improvements in teamwork among all clinical team members. The providers, nurses, and staff participate in clinical scenarios that likely resonate with previous experiences, and during the debriefings, they bring knowledge and reflections from these real and simulated experiences to team discussions of how to improve communication and the environment and how to respond to emergencies. Debriefings after simulation motivate team members to reflect on their practice, draw from their prior experiences, and share them as a team to understand differences in understandings to
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develop a shared model and resolve issues. More recently trained clinical professionals had experienced simulation during their education and were skeptical at first about its effectiveness and safety. For example, some of the nurses who had experienced training through simulation had not liked being observed and judged (graded). However, as fully trained professionals, they now expressed their appreciation of the opportunity that simulation provided to practice skills that they do not often use. Both experienced and inexperienced clinicians embraced the in situ training experience. The experiential learning provided through simulation proved to be a particularly effective method for clinicians to learn concepts not traditionally included in clinical training, such as strategies for effective communication and teamwork. In addition, being able to provide the program in the participants’ own clinical environment extends the value of training beyond the individual or team to improving safety and quality for the entire system. Not only was it useful to rehearse the response to a given emergency, the process of debriefing provided the unique opportunity for team members to stop and talk about a shared experience and to understand the experience and process it from other coworkers’ perspectives. Ultimately, this understanding may help the participants become better team members by discussing patterns of behavior that can be misinterpreted and by working together on a common topic to truly improve the entire process of care.40 Follow-up simulations also provided the opportunity to test systems and behavior improvements that had been put into place by each institution. The mobile in situ simulation and teamwork training approach appears to be a cost-effective mechanism to enhance and maintain skills, promote improved teamwork, identify pertinent local systems issues, and ultimately improve safety. Local hospitals may not be able to afford the cost of running a local simulation program; the equipment is expensive, the human resources required to run simulations—particularly team simulations—are considerable, and there is no central repository of evidence-based scenarios and education for easy use. If a local hospital is interested in developing a simulation program, it may want to consider partnering with other local hospitals, universities, or community colleges to share the burden of costs. Alternatively, there are numerous simulation centers around the world that offer various simulation and/or team training programs for individuals or groups, as can be found on the Web sites of simulation societies. However, the cost and inconvenience of traveling to simulation centers for training are considerable, and the effectiveness of the training, particularly
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The Joint Commission Journal on Quality and Patient Safety teamwork training, is potentially limited, because only a few members at most can leave the institution for training at any one time. Mobile simulation programs offer a potential solution for both of these issues, while also enabling the provision of in situ simulation to evaluate the degree to which local hospital systems and the physical environment promote safe, efficient, and effective care. Mobile simulation is new, so it can be challenging to find mobile simulation programs; however, often their mobile nature means they are able to travel large distances. In conclusion, studies are increasingly indicating an important role for in situ simulation in the promotion of patient safety; continuing to share lessons learned is important as the field matures. J Development and testing of the program was provided through a grant from the Agency for Healthcare Research and Quality Grant 1 U18-HS015800-02.
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See the online version of this article for
Figure 1. Simulation Algorithm for Standard Vaginal Delivery Scenario
Jeanne-Marie Guise, M.D., M.P.H., is Associate Professor, Division of Maternal Fetal Medicine, Departments of Obstetrics and Gynecology, Medical Informatics and Clinical Epidemiology, and Public Health and Preventive Medicine, and Director of the State Obstetric and Pediatric Research Collaborative (STORC) and Quality and Safety for Women’s Services for Oregon Health & Science University, Portland, Oregon. Nancy K. Lowe, Ph.D., C.N.M., is Professor and Chair, Women, Children, & Family Health, College of Nursing, University of Colorado Denver, Aurora, Colorado. Shad Deering, M.D., is a Maternal Fetal Medicine Staff and Medical Director, Andersen Simulation Center, Madigan Army Medical Center, Tacoma, Washington. Patricia O. Lewis was Senior Research Assistant, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University. Christen O’Haire, Ph.D., is Epidemiologist and Program Coordinator for the Mobile Simulation Program, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University. Lori K. Irwin, R.N., M.S., is Perinatal Clinical Nurse Specialist, Women and Children Services, Oregon Health & Science University/ Doernbecher Children’s Hospital, Portland, Oregon. Molly Blaser, R.N., M.N., is Nursing Manager, Labor & Delivery, Oregon Health & Science University. Laurie S. Wood, M.S., R.N., C.N.A.-B.C., is Director, Obstetrical Services, Maricopa Integrated Health Systems, Phoenix. Barbara G. Kanki, Ph.D., is Research Psychologist, Human-Systems Integration Division, National Aeronautics and Space Administration, Ames Research Center, Moffett Field, California. Please address correspondence to Jeanne-Marie Guise, [email protected].
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References 1. Hamilton B.E., Martin J.A., Sutton P.D.: Births: Preliminary data for 2003. Natl Vital Stat Rep 53:1–17, Nov. 23, 2004. 2. Jiang H., et al.: Care of women in U.S. hospitals, 2000. 2002 HCUP Fact Book No. 3. Agency for Healthcare Research and Quality, 2002. http://www.ahrq.gov/data/hcup/factbk3/ (last accessed Aug. 24, 2010). 3. Johanson R.B., et al.: Managing obstetric emergencies and trauma (MOET) structured skills training in Armenia, utilising models and reality based scenarios. BMC Med Educ 2:5, May 2002. 4. Baldisseri M.: Amniotic Fluid Embolism Syndrome. http://www.uptodate.com/patients/content/topic.do?topicKey= ~mJJmAFbjGf455V&selectedTitle=1%7E17&source=search_result. (last accessed Aug. 24, 2010). 5. The Joint Commission: Preventing infant death and injury during delivery. Sentinel Event Alert. Issue 30, Jul. 21, 2004. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/ sea_30.htm (last accessed Aug. 24, 2010). 6. Maternal and Child Health Research Consortium: 7th Annual Report of the Confidential Enquiry into Stillbirths and Deaths in Infancy. Jun. 2000. http://www.cmace.org.uk/getattachment/b858e5e8-862a-4121-9348b9284d02db1b/7th-Annual-Report.aspx (last accessed Aug. 24, 2010). 7. Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999. 8. U.K. Department of Health: Why Mothers Die: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, 1994–1996. Norwich, UK: The Stationary Office, 1998. 9. White A.A., et al.: Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 105:1031–1038, May 2005. 10. Singh H., et al.: Medical errors involving trainees: A study of closed malpractice claims from 5 insurers. Arch Intern Med 167:2030–2036, Oct. 2007. 11. Shojania K., et al.: Making Health Care Safer. A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43. Rockville, MD: Agency for Healthcare Research and Quality, 2001. 12. Gayman A., et al.: Implications of crew resource management training for tank crews. Paper presented at the Interservice/Industry Training System and Education Conference, Orlando, FL, 1996. 13. Grubb G., Simon R., Zeller J.: Effects of crew coordination training and evaluation methods on AH-64 attack helicopter battalion crew performance. Arlington, VA: U.S. Army Research Institute for the Behavioral and Social Sciences, 1993. 14. Salas E., et al.: Team training in the skies: Does crew resource management (CRM) training work? Hum Factors 43:641–674, Winter 2001. 15. Chopra V., et al.: Does training on an anaesthesia simulator lead to improvement in performance? Br J Anaesth 73:293–297, Sep. 1994. 16. Holzman R.S., et al.: Anesthesia crisis resource management: Real-life simulation training in operating room crises. J Clin Anesth 7:675–687, Dec. 1995. 17. Howard S.K., et al.: Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63:763–770, Sep. 1992. 18. Ballaro A., et al.: A computer generated interactive transurethral prostatic resection simulator. J Urol 162:1633–1635, Nov. 1999. 19. Bettega G., et al.: A simulator for maxillofacial surgery integrating 3D cephalometry and orthodontia. Comput Aided Surg 5(3):156–165, 2000. 20. Carrico C., Satava R.: Advanced simulation technologies for surgical education. Bull Am Coll Surg 81(7):77, 1996. 21. Chong C.K., et al.: Development of a simulator for endovascular repair of abdominal aortic aneurysms. Ann Biomed Eng 26:798–802, Sep.–Oct. 1998. 22. Derossis A.M., et al.: The effect of practice on performance in a laparoscopic simulator. Surg Endosc 12:1117–1120, Sep. 1998. 23. Fried G.M., et al.: Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator. Surg Endosc 13:1077–1081, Nov. 1999.
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The Joint Commission Journal on Quality and Patient Safety 24. Gordon J., Brown D., Armstrong E.: Can a simulated critical care encounter accelerate basic science learning among preclinical medical students? A pilot study. Simul Healthc 1:13–17, Jan. 2006. 25. Sutherland L.M., et al.: Surgical simulation: A systematic review. Ann Surg 243:291–300, Mar. 2006. 26. Szekely G., et al.: Virtual reality based surgery simulation for endoscopic gynaecology. Stud Health Technol Inform 62:351–357, 1999. 27. Advanced Life Support in Obstetrics [course syllabus]. Leawood, KS: American Academy of Family Physicians, 1993. 28. Deering S., et al.: Simulation training and resident performance of singleton vaginal breech delivery. Obstet Gynecol 107:86–89, Jan. 2006. 29. Deering S., et al.: Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol 103:1224–1228, Jun. 2004. 30. Deering S.H., Satin A.J.: Teaching infrequently used skills: Vaginal breech delivery [comment]. Obstet Gynecol 104:191–192, Jul. 2004. 31. Thomas E.J., Sexton J.B., Helmreich R.L.: Translating teamwork behaviours from aviation to healthcare: Development of behavioural markers for neonatal resuscitation. Qual Saf Health Care 13(suppl. 1):57–64, Oct. 2004. 32. Thomas E.J., et al.: Teamwork and quality during neonatal care in the delivery room. J Perinatol 26:163–169, Mar. 2006. 33. Crofts J.F., et al.: Change in knowledge of midwives and obstetricians fol-
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lowing obstetric emergency training: A randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 114:1534–1541, Dec. 2007. 34. Crofts J.F., et al.: Observations from 450 shoulder dystocia simulations: Lessons for skills training. Obstet Gynecol 112:906–912, Oct. 2008. 35. Draycott T.J., et al.: Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 112:14–20, Jul. 2008. 36. Draycott T., et al.: Does training in obstetric emergencies improve neonatal outcome? BJOG 113:177–182, Feb. 2006. 37. Smits A.K., et al.: Factors influencing cessation of pregnancy care in Oregon. Fam Med 36:490–495, Jul.–Aug. 2004. 38. Centers for Medicare & Medicaid Services (CMS): EMTALA Emergency Medical Treatment and Active Labor Act: http://www.cms.gov/EMTALA/ (last accessed Aug. 23, 2010). 39. Patterson E., Roth E., Woods D.: Facets of complexity in situated work. In Patterson E.S., Miller J. (eds.): Macrocognition Metrics and Scenarios: Design and Evaluation for Real-World Teams. Farnham, UK: Ashgate Publishing, 2010. 40. Pian-Smith M.C., et al.: Teaching residents the two-challenge rule: A simulation-based approach to improve education and patient safety. Simul Healthc 4:84–91, Summer 2009.
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Figure 1. Simulation Algorithm for Standard Vaginal Delivery Scenario Scenario Algorithm
Scenario Scene 28-year-old woman at 38 weeks. Confederate (support person) calls out and says, “The baby is coming.”
Baseline
Scenario Background Chief Complaint Baby’s coming
Visible crowning
Past Medical History No prenatal care History of quick labor with vaginal delivery at term, no complications
Delivery of infant
Social History Sister at bedside Drug Allergies None
Cord is quickly cut
Baby to warmer
Placenta delivery intact
Heart rate 120 and breathing
Evaluation Baby stable
Medications Prenatal vitamins
Mother stable
Learning Objectives Primary Technical Objectives 1. Recognize delivery and basic delivery skills 2. Demonstrate the ability to assemble adequate staff to care for mom and infant Primary Team Objectives 1. Demonstrate ability to give SBAR (form of orientation) to team 2. Closed-loop communication Secondary Technical Objectives 1. Obtained SBAR upon arrival Secondary Team Objectives 1. Role clarity 2. Directed communication 3. Effective in leading team
(continued)
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Figure 1. Simulation Algorithm for Standard Vaginal Delivery Scenario (continued) Standard Vaginal Delivery What Ifs? 1. Provider is not able to go to OR (Anesthesia has been called and is in another room) 2. Delivery 3. Assessment 4. Resolution Personnel Hot seats/Trainees Delivery Option #1 = 1 nurse; 1 doctor/midwife Option #2 = 1 nurse; 1 doctor/midwife; 1 nurse backup; 1 doctor/midwife backup Resuscitation Team Not applicable Instructor/Confederate Roles Lead debriefing instructor Associate debriefing instructor Voice of the patient +/– family member/observer Confederate nurse (new nurse trained in OB available to you to assist you) Person running mannequin
Confederates +/– significant other crying and grabbing people to help him understand what is going on Equipment/Supplies Neonate Warming bed Radiant warmer bag/mask/suction/oxygen Intubation equipment; bulb/DeLee Stethoscope Blankets Maternal Maternal delivery mannequin Delivery tray with supplies Blood pressure machine Normal fetal monitor tracing Step Vitals Remain normal Mom: blood pressure 120/60, pulse 80
Team Scenario Notes Debriefing Notes ⻬ Target fixation ⻬ Transparent thinking ⻬ Conflict resolution ⻬ Technical skills—normal spontaneous vaginal delivery ⻬ Obtain SBAR—talk about explicit versus implicit communication. ⻬ Role clarity—who was in charge? ⻬ Explore the role of event manager. ⻬ Advocating and asserting a position or corrective action ⻬ Directed communication, use of first names
Figure 1. The simulation algorithm for a standard delivery scenario is shown. Adapted from Gordon J.A.: 6 Macy Cases for Realistic Patient Simulation in Critical Care and Emergency Medicine. Harvard Medical School, 2002. http://www.harvardmedsim.org/Macy_cases.pdf (last accessed Dec. 17, 2008; no longer available). SBAR, Situation-Background-Assessment-Recommendation; OR, operating room; OB, obstetrics.
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Mobile In Situ Obstetric Emergency Simulation and Teamwork Training to Improve Maternal-Fetal Safety in Hospitals Jeanne-Marie Guise, M.D., M.P.H.; Nancy K. Lowe, Ph.D., C.N.M.; Shad Deering, M.D.; Patricia O. Lewis; Christen O’Haire, Ph.D.; Lori K. Irwin, R.N., M.S.; Molly Blaser, R.N., M.S.; Laurie S. Wood, M.S., R.N., C.N.A.-B.C.; Barbara G. Kanki, Ph.D.
C
hildbirth is the most common reason for admission to the hospital for women, with more than 4 million children born each year at approximately 6,000 hospitals in the United States.1,2 Obstetric emergencies can present in otherwise healthy, low-risk women at term, complicating up to 15% of all births.3 Emergencies such as amniotic fluid embolism (AFE) occur rarely (estimated at one in 8,000–30,000 pregnancies), yet the consequences can be profound. More than half of women who suffer an AFE die within the first hour after symptoms present.4 Efficient recognition and appropriate response by clinical teams are critical; however, given the rarity of such obstetric complications, decades can pass before a health care worker would see a case, making it challenging for teams to remain confident, competent, and efficient in responding. Communication issues also compound the challenge of responding to infrequently occurring emergencies. The Joint Commission5 and other international organizations6–8 consistently report that communication failures and lack of teamwork are major contributors to adverse obstetric outcomes. The Joint Commission reported that human factors issues such as communication were attributable for 2/3 of sentinel neonatal events.5 Similarly, a confidential inquiry in England found that suboptimal care was associated with 75% of stillbirths.6 In addition, lack of teamwork and poor communication have been found to be significant contributors to malpractice claims and have been estimated to be associated with as many as onethird of closed obstetric malpractice cases.9 One report found that teamwork and communication problems were accountable for 71% of closed claims that involved medical residents or fellows, suggesting that the problem may be more extensive in training institutions.10 Yet, traditional clinical training does not provide education on communication strategies and teamwork. After discovering nearly 40 years ago that human factors issues such as communication and teamwork were responsible for 60%–80% of plane crashes, the aviation community
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Article-at-a-Glance Background: Evidence from other high-risk industries
has demonstrated that teamwork skills can be taught and effective teamwork may improve safety. Increasingly, health care providers, hospital administrators, and quality and safety professionals are considering simulation as a strategy to improve quality and patient safety. Mobile Obstetric Simulation and Team Training Program: A mobile obstetric emergency simulation and team training program was created to bring simulation technology and teamwork training used routinely in other high reliability fields directly to health care institutions. A mobile unit constituted a practical approach, given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites. Between 2007 and 2009, in situ simulation of obstetric emergencies and teamwork training was tested with more than 150 health care professionals in labor and delivery units across four rural and two community hospitals in Oregon. How Do Organizations Determine Which Type of Simulation Is Best for Them? Because simulation technologies are relatively costly to start and maintain, it can be challenging for hospitals and health care professionals to determine which format (send staff to a simulation center, develop in-house simulation program, develop a consortium of hospitals that run a simulation program, or use a mobile simulation program) is best for them. Conclusions: In situ simulation is an effective way to develop new skills, to maintain infrequently used clinical skills even among experienced clinical teams, and to uncover and address latent safety threats in the clinical setting.
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The Joint Commission Journal on Quality and Patient Safety embraced crew resource management (CRM) and simulation to train aviation teams in teamwork and to provide them with a venue to practice essential teamwork skills.11 The development of routine simulation and teamwork training in aviation exercises may have been a primary contributor to the dramatic reduction in fatal plane crashes in the past several decades.12–14 Increasingly, clinicians, hospital administrators, and quality and safety professionals are considering simulation as a strategy to improve health care quality and patient safety. Numerous studies have demonstrated the realism and educational value of simulation in medical training.15–17 In addition, several studies have examined simulation as a mechanism to transmit and improve the retention of knowledge and technical skills.18-26 However, few studies have evaluated simulation as a method to improve obstetric emergency response and safety for clinical teams.3,27–30 Thomas et al., who observed teamwork during neonatal resuscitations in the delivery room, found that most teamwork skills can be reliably evaluated.22,31,32 They also identified three main factors that were associated with good teamwork: communication, management of work load/resources, and leadership. Draycott et al. have also conducted several interesting studies relating to simulation and obstetric safety.33–36 In one of these studies, they reported a significant decrease in the rate of hypoxic ischemic encephalopathy from 27.3/10,000 before simulation training to 13.6/10,000.36 This emerging evidence suggests that simulation can play an important role in improving health care delivery and health outcomes. Importantly, very little is known about the value of and considerations for in situ (in the clinical setting) simulations across practice settings, particularly in the high-risk field of maternity care. We developed a mobile obstetric emergency simulation and team training program to examine whether there was value for in situ simulation for experienced clinical teams from rural and community hospitals in Oregon. Given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites, the creation of the mobile unit was a practical approach. Oregon has been one of the crisis states for obstetric care, with one survey conducted in late 2002, for example, indicating that one-third of maternity providers, of whom 66% were rural care providers, planned to stop delivering babies in the subsequent one to five years.37 The reasons cited by providers for ceasing to provide obstetric services included liability insurance costs, fear of lawsuits, low patient volume, and concern for 444
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skill level. Rural hospitals are particularly strained, given that they are required, through the Emergency Medical Treatment and Active Labor Act (EMTALA), to provide emergency services for delivering or laboring pregnant women.38 Yet they have limited resources, few skilled maternity providers, and infrequent hands-on experience with such emergencies. Considering these obstacles, we focused the mobile obstetric emergency simulation and team training program on rural and community hospitals, with the thought that access to training opportunities may be particularly limited. In this article, we describe the process of developing an emergency simulation curriculum, discuss the advantages of in situ simulation, and share lessons learned and describe patient safety improvements that can result from conducting in situ simulation training.
Mobile Obstetric Simulation and Team Training Program BACKGROUND In 2005 we partnered with the founders of CRM at the National Aeronautics and Space Administration (NASA) and experts in skills-based simulation through a grant from the U.S. Agency for Healthcare Research and Quality to develop a selfcontained mobile obstetric simulation and team training program. The goal of the program was to bring simulation technology and teamwork training that is used routinely in other high-reliability fields directly to health care institutions to improve the processes of obstetric care and to promote safety. This goal was based on the operating principles shown in Table 1 (page 445). Furthermore, the intent of the curriculum was to “transform good teams into extraordinary teams” through teamwork training and practice responding to infrequent obstetric events to ultimately improve outcomes for mothers and babies. Between 2006 and 2008, we conducted testing with more than 150 health care professionals to determine whether in situ simulation of obstetric emergencies and teamwork training could improve the process of care and patient safety in labor and delivery (L&D) units across six different hospital settings in Oregon—four rural and two community hospitals—with 45 to more than 1,600 deliveries a year.
RECRUITMENT Hospitals were purposively selected for geographic, hospital, and practice diversity. Initial visits were conducted presenting the program to hospital, practice, and nursing leadership, and participation agreements were signed. All hospitals approached
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The Joint Commission Journal on Quality and Patient Safety Table 1. Operating Principles 1. Physicians, nurses, and other health care staff are well-trained, knowledgeable experts in their fields who are deeply dedicated to providing high-quality patient care. 2. Obstetric emergencies occur infrequently, and practice may support clinician’s confidence and efficiency in responding. 3. Interdisciplinary teams whose members respond together should train together. 4. In situ simulation in the familiar clinical setting is the best way to improve safety and activate team members to learn and practice best-evidence team skills. 5. Adult learners learn and retain skills well through practice.
agreed to participate in both an initial simulation and team training and a follow-up simulation visit to measure retention and adaptation of skills.
OUTLINING
THE
EDUCATIONAL SESSION
We outlined the educational session as follows: 1. Introduction to simulation, with the opportunity to conduct a simulated normal vaginal birth 2. Emergency simulation scenario no. 1 3. Facilitated team debriefing, followed by a standardized clinical didactic focused on the specific emergency of the first simulation and a standardized teamwork skills didactic 4. Emergency simulation scenario no. 2 5. Facilitated team debriefing followed by a standardized clinical didactic focused on the specific emergency of the second simulation
DEVELOPING A MEANINGFUL CURRICULUM Engaging Stakeholders in Development. In developing the program, we—as members of the interdisciplinary team— spoke with hospital leaders around the state, who stated that they were dedicated to patient safety but echoed a practical reality that was well described by one CEO: “Our staff are time constrained and it is hard to get them away from patient care to improve their patient care.” This meant that the curriculum needed to be short, engaging, accessible, and clinically important and have a high perceived return on investment. Meeting the Needs of the Whole Team Through an Interdisciplinary Development Process. Curriculum development began by focusing on clinically important topics pertinent to interdisciplinary clinical teams. In general, we chose to simulate obstetric emergencies, such as shoulder dystocia, postpartum hemorrhage, and eclampsia, because their time-critical nature makes communication and teamwork issues apparent,
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their emotional charge and impact activate experiential learning, and their infrequent nature and high stakes make them ideal for repetition through simulation. When running interdisciplinary simulations for clinical teams, it is important for the simulation to have face validity across the range of professionals with representative complexity and reasonable scenario difficulty for each role.39 Representatives from all disciplines that would respond clinically to a particular emergency worked together to develop each simulation scenario. This proved to be a tremendous asset, helping to ensure that the simulation scenario was valid to all clinical participants and included important elements for each participant. An alternative development approach is to have one person draft the initial scenario, circulate the draft among the team members for revision, and then further refine the scenario when it is used in simulation. The potential drawbacks to the latter approach is that it can be more time consuming, can be particularly draining on the individual creating the scenario, makes buy-in from other disciplines more difficult, and has a higher risk of poor scenario integrity, with inconsistencies or problems when the scenario runs in the interdisciplinary setting. We found that scenario development by a representative interdisciplinary group was efficient, promoted collegiality, increased buy-in across specialties, was enjoyable, and made us more aware of incorrect assumptions participants were likely to hold that may affect teamwork or clinical behaviors. Organized Approach. It is important for simulation development to use an organized approach. Following the case outline adapted from the Harvard Simulation Center by James Gordon, Brown, and Armstrong,24 our interdisciplinary team met to outline each scenario, develop primary and secondary learning objectives, and detail the technical requirements of the scenario (Figure 1, available in online article). In developing the scenarios, we determined what key findings, responses, or behaviors were expected from various team members. These key elements determined the length of the scenario by specifying endpoints, as well as the critical teaching points for the didactic. For example, depending on the desired key elements, we may have specified that a vaginal delivery ended with the birth of the baby or after a particular sequence in neonatal resuscitation. In addition, we set a time limit for each scenario that was observed even if all desired behaviors were not demonstrated. We also sought to protect participants by ensuring that no matter what happened, the mother or baby never died during simulation. Research in the aviation field has indicated that such traumatic simulation experiences can make participants fearful of ever stepping into the cockpit again, real or simulated.
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The Joint Commission Journal on Quality and Patient Safety Detailed Script. After we finalized the overall outline for the scenario and learning objectives, we wrote a detailed script for all confederate dialogue, technical requirements, and possible variations in flow of the simulation. We then verbally walked through the script, and, following any needed revisions, completed at least one run-through, with our team members playing the roles of participants. To finalize the script and technical requirements, we had interdisciplinary teams who were not involved in the curriculum development participate in the simulation to identify unanticipated behaviors or technical issues. Evidence-Based Clinical Didactics. In addition to the simulation scenarios, we developed an evidence-based clinical didactic specific to the clinical problem of each scenario. Each didactic was designed to be succinct and clinically relevant by focusing on issues that all L&D team members need to know. Our didactics did not cover the typical epidemiology and pathophysiology of the clinical problem but included the most common predisposing factors, presenting symptoms, treatments, and other clinically important considerations, such as what each medication looks like, dose and route of administration, how long it takes to administer, and so on. Interdisciplinary team members expert in conducting systematic reviews assisted in ensuring that all aspects of curriculum development followed an evidence-based process. The didactics were standardized as electronic video files, including a PowerPoint® presentation, instructional film vignettes, and voice-over by an instructor. Didactics, ranging from 4 to 14 minutes, were consistent with the complexity of the management of specific obstetric emergencies. Teamwork Skills. Despite the provision of the clinical didactics, the curriculum’s focus was the development of teamwork skills rather than the specific clinical skills unique to each simulation scenario. Therefore, each scenario had primary and secondary teamwork learning objectives, such as the following: ■ Using SBAR (Situation, Background, Assessment, Response) to orient team members as they arrive to the situation ■ Transparent thinking (thinking out loud) among team members ■ Directed and closed-loop communication (directing communication to a particular person either by using their name or visual cues and confirming receipt of the message) The companion teamwork didactic, which was designed to be interchangeable with any clinical topic, provided concise best practices in teamwork and was followed by video clips portraying how each skill could be used in obstetrics. For example, the didactic included an example of transparent thinking in an 446
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Table 2. Teamwork Didactic Content 1. Communication Orientation: Situation, Background, Assessment, Response (SBAR) Transparent thinking (thinking out loud) Directed communication Closed-loop communication 2. Situational Awareness/Resource Allocation/Backup Behaviors Call for help early Know all human and technological resources available and how to access them quickly Backup behaviors/cross-monitoring Avoid target fixation (tunnel vision) Situational awareness/performance monitoring Consider event manager 3. Role Clarity/Leadership 4. Decision Making and Cross-Monitoring Prioritize other responsibilities appropriately
obstetric emergency so a provider who typically is not comfortable thinking out loud can see how the skill might be done and potentially try it in the next simulation scenario. Topics covered in the teamwork didactic are outlined in Table 2 (above).
RESOURCES FOR CONTINUED LEARNING We intentionally kept our field didactics brief, focusing only on those things that everyone in the room needed to know. However, simulation can prompt participants to want to learn more about a given topic. For this purpose, we developed a teamwork training manual for distribution and also provided a book that contained greater depth of information on clinical topics.
TECHNICAL CONSIDERATIONS The curriculum was designed to be entirely self-contained so that participating institutions only needed to reserve one patient room and a second room to conduct private debriefings. Other than locally supplied delivery packs and linens, we brought all equipment and supplies necessary to run the scenarios and the debriefings (Table 3, page 447). Although we purchased the top-of-the-line obstetric simulator with all the technological capabilities of the time, we found that for mobile simulation it was optimal not to use many of the hightechnology (-tech) options. We found that response time was critical because clinicians expected responses to their maneuvers and interventions without substantial delay, similar to what they would see in real life. Rapid response times were difficult
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The Joint Commission Journal on Quality and Patient Safety Table 3. Mobile Simulation Equipment Simulation Equipment Gaumard Noelle S550™ obstetric simulator Advanced Medical Simulations FetalSim™ fetal heart rate simulator that connects to local fetal monitor Gaumard PEDI® Blue Neonate Extra parts and repair supplies for simulator in case of breakdown Dictaphone with recorded fetal heart sounds if needed Debriefing Equipment 19-inch television monitor Mini-digital video (DV) recorder with boom DVD video recorder with boom Other Equipment Scenario-specific kits (e.g., simulated medications, simulated blood, equipment) Mobile cart to transport equipment Cleaning supplies
to achieve using standard programming of the simulators available at the time. For example, in a shoulder-dystocia scenario using computer-guided delivery, if the participant wanted to perform a Zavanelli maneuver (replacement of the fetal head into the pelvis), the computer-controlled motor would reverse the direction rather slowly and create a constant force that is not typical of a live woman and fetus. Second, certain technical features of the high-tech equipment made it very hard for participants to suspend disbelief (an important contributor to the value of the simulation). For example, the motor that drives the baby down the abdomen in the simulation mother was very loud and made noises that no woman would make even in the most difficult labor. Third, the number and length of cords connected to the simulator mannequin limited our mobility and the maneuvers the participants could use. Because of this, we most often chose a low-tech approach to provide versatility. We created a harness for the baby that one of our staff (playing the role of labor support person) held to control the descent/ascent of the baby and respond to maneuvers used by the participant. We also created PowerPoint presentations for vital signs to enable us to change more quickly between vitals with and without oxygen saturations or to quickly respond to a request for another set of vital signs. In addition, we inserted audio onto the slides as indicated. For example, audio of a crying baby was inserted when resuscitation of the newborn was not a focus of the scenario and we wanted the team to attend to the mother. We created other simple low-tech solutions to simulate events, such as seizures that we wanted to control
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regardless of the position of the mannequin. We did feel, however, that investment in a separate fetal simulator was worthwhile because it allowed us to plug into any local fetal monitor so the fetal tracing and audio were similar to the participants’ normal clinical reality. In obstetrics, the constant background monitoring of the fetal heart sounds made this element important to engage participants in the simulation.
SCHEDULE AND CONSENT After all the pieces were developed, we planned a typical onsite schedule for how many teams we could accommodate for training per day, with the curriculum for each team requiring 2.5 hours. At the beginning of the in situ training, each participant was asked to sign a video consent to permit simulation videotaping required for debriefing and a confidentiality agreement to ensure that “what happens in simulation stays in simulation” and that participants out of professional respect hold in confidence their colleagues’ performances.
SPECIAL CONSIDERATIONS FOR IN SITU SIMULATION We visited every site before scheduling the on-site training to meet with hospital, nursing, and practice leaders. The purpose of this visit was to obtain buy-in, understand local team structure and care processes, identify key contacts who could schedule teams for the simulation curriculum and coordinate our technical needs during our visits, and to sign agreements. Conducting simulations in the location where care is delivered is convenient for staff and maximizes learning because the participants are in their familiar clinical environment. This approach is also useful to explore and analyze systems issues that affect care delivery during emergencies. However, there are unique issues that are important to consider when simulating in the clinical environment. We learned that we needed four to five staff members for each trip—including two clinicians trained in simulation debriefing, a registered nurse, a “voice” (someone who is behind the patient drape, at the head of the mannequin, and who also worked as a technician for the simulation mother), and a videographer. The two clinicians rotated between the instructor/debriefer role and a support person for the mother—a role that usually included conducting technical aspects of running the specific scenario. Another important consideration is medication safety. Companies sell simulated medications, blood, and so on, that look exactly like the real thing. However, just as in clinical care, it is possible that a participant could put a simulated medication in a pocket or other place that would directly affect patient care by making it possible for a simulated medication to be
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The Joint Commission Journal on Quality and Patient Safety given to a real patient. To eliminate this risk, we created simulated medications that were clearly labeled with drug name and dosage, in correctly sized dispensers for sufficient realism but also clearly identifiable as simulated medications (that is, visually distinct from real medications). This way, even if a simulated medication is left behind, it is obvious that it is not to be used clinically. Another consideration for in situ simulation is how participants normally access equipment or medications, where these items are normally located, and how they are acquired for bedside use. Because people commonly need to go to machines such as a Pyxis® (automated medication dispensing system) to obtain equipment or medications, we have a staff member act as a “human machine” outside the simulation room. If the nurse or other staff must go to a machine for a specific medication or item, our “human Pyxis” asks the participant for the information required for Pyxis entry and has the participant wait the amount of time it would take to walk from the room to the Pyxis and back again. Other local considerations include central monitoring that should be disabled for the simulation, code buttons or call light systems that should be covered or disconnected, locations of various equipment or other needs that will be simulated, and in-room sharps containers that need to be taped over so that simulated medications are not lost. We kept all our items organized according to scenario both for ease of set up and also to allow preparation of items from a checklist. Finally, taking simulation into the clinical setting required flexibility and ingenuity on the part of the simulation team to respond to local challenges. For example, the unpredictable nature of obstetrics sometimes resulted in L&D rooms being occupied by real patients when we were scheduled to conduct simulations. In these situations, we often used rooms considered overflow space. Although the participating institutions found this undesirable, in reality it offered the opportunity to test the physical plant and systems issues that often come up when patient census is high. We also adapted to high patient census through flexibility in the debriefing location. Debriefing can be effectively done in any room as long as there is privacy and enough room for the participants and debriefer to be comfortably seated facing each other. We have used empty patient rooms, consultation rooms, private staff lounges, and miscellaneous other hospital rooms for debriefing.
How Do Organizations Determine Which Simulation Format Is Best for Them? Human patient simulators are implemented in a number of 448
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clinical and educational settings with a variety of intentions. Table 4 (page 449) presents issues that organizations may want to consider when debating whether center-based simulation or in situ simulation is best for them. The goals of simulation conducted in situ may differ from simulation conducted in simulation centers. For example, simulation that is conducted in the clinical setting is uniquely connected to the clinical setting in which clinical care is provided, and so it is uniquely suited to identify systems issues and inefficient or incorrect responses among clinical teams. Simulation centers have the unique ability to have multiple high-tech simulation equipment setups, making this setting uniquely able to provide efficient instruction in technical skills acquisition and use simulation as a part of a larger didactic curriculum. Similarly, because in situ simulation requires purchase of only the simulation equipment itself, in situ simulation or mobile in situ simulation provides institutions with the opportunity to try simulation training before deciding to invest in the development and building of a simulation center.
Findings and Advantages of In Situ Simulation One of the most compelling reasons to conduct in situ simulation is the ability to identify latent quality and safety issues in the clinical environment while refreshing knowledge and clinical skills among clinical teams. As shown in Table 5 (page 450), consistent themes emerged among sites regarding latent quality and safety issues that were identified in conducting simulated obstetric emergencies in situ. The most common problem was inconsistent information on medications and knowledge about emergency medications such as those used to treat postpartum hemorrhage. Providers and staff often lacked knowledge about medication dosing, route of administration, and contraindications to medications that were not used frequently. Examples of behaviors observed during the emergency involving medications included administration of the most commonly used medication even when it was contraindicated for that patient, administration of medications through improper routes, and delays in administration caused by uncertainty for route of delivery. Solutions implemented by several hospitals included the development of emergency-specific (for example, obstetric hemorrhage) kits that contain all possible medications, equipment required to administer the medications, and a card containing accurate information of the medication route, dose, and contraindications. The kit served as a memory aid, but it also improved efficiency for obtaining medications in an emergency because all medications were now stored in one location.
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The Joint Commission Journal on Quality and Patient Safety Table 4. Comparison of Center-Based Simulation to In Situ Simulation Center-Based Simulation
Suggestions for In Situ Simulation
Elaborate Technology Possible ■ Highly sophisticated computers ■ One-way glass ■ Control station; simulation team communicates freely
Simple Technology Preferred ■ Low-tech computers simplify connectivity and technical difficulties ■ No physical barriers between participants and simulation personnel (with exception of sheet at head for live voice) ■ No control station; all personnel communicate in role
Convenience ■ Convenient for simulation personnel ■ Challenging for participants (travel, unfamiliar environment, and equipment) ■ Less likely that all personnel from the clinical settings could simultaneously participate (often individuals bring back lessons learned to local group) ■ May limit combined-team opportunities
Convenience ■ Challenging/inconvenient for simulation personnel (travel, unfamiliar environment/equipment, frequent set-ups) ■ Convenient and familiar to participants ■ Clinical teams can respond in simulations with their partners in the real clinical setting (promotes and reinforces group learning and adoption).
Scheduling ■ Need to arrange substantial time away from clinical activities for staff to attend ■ Reliably available at time when the simulation is scheduled ■ May offer expanded time for simulation and debriefing
Scheduling ■ Staff can participate while working (need to arrange cross-coverage for smaller times). ■ Less reliable scheduling because clinical volume may result in all rooms being full and need to reschedule ■ May be more time pressure for simulation and debriefing
Medication Safety & Clinical Equipment ■ Medications can appear identical to real medications (little risk for use in real life). ■ Use Center equipment, which may not match local clinical equipment
Medication Safety & Clinical Equipment ■ Simulated medications intentionally appear fake to prevent administration to real patients. ■ Can use familiar local medical equipment (e.g., units’ electronic fetal monitors) ■ Allows for immediate identification of some safety issues in own clinical environment
Debriefing ■ High-tech room (with computer/video overlays possible)
Debriefing ■ Can use any private room close to simulation ■ Video must include important visuals (not conducive to overlays).
Team Training Implications ■ Can teach teamwork principles ■ Able to mix classroom setting and simulated clinical setting ■ May be more challenging to transfer teamwork skills to clinical setting because of the following: –Limited personnel in attendance –Lack of familiar triggers to imprint into “muscle memory”
Team Training Implications ■ May be easier to transfer teamwork skills to clinical setting because of the following: –Actual clinical teams practicing and learning together –Familiar surroundings to trigger to imprint into “muscle memory”’ –Clinical setting may increase meaning and activate learning among participants
Another common issue involved stocking of the rooms, particularly checking emergency equipment, which was not commonly used. Several hospitals indicated there was either no clear person assigned to stock rooms, the nurse caring for the patient was supposed to restock rooms after a delivery, or a person was designated but there was no comprehensive list of items to be stocked. During simulation, it was commonly observed that nurses would need to leave their patient to obtain missing
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equipment. Even in hospitals where roles were assigned, items that were infrequently used, such as the emergency phone and resuscitation equipment were not available during the emergency—for example, laryngoscope pieces were missing or batteries for the laryngoscope did not work. Another common theme that the simulations uncovered at many institutions was inconsistent understandings of roles and expectations of individuals. This was most commonly discov-
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The Joint Commission Journal on Quality and Patient Safety Table 5. Quality Issues Identified and Improved Through Simulation* Quality Issues Identified A Environment/Room Stocking and Storage Room stocking (e.g., vacuum, respiratory therapy, IV equipment) inconsistent or did not have designated individual to stock room Stool in bathroom farthest from patient and often blocked Tracking Time Unaware of ability of fetal monitor to mark time Inconsistently marked time Clock out of nurse's line of vision Clinical Information Posters in room illustrate improper techniques (e.g., McRoberts technique)
B
Hospital C D
Solutions E
F
– –
+ –
– +
+ –
+ –
+ –
+ – –
– + –
– – –
– – +
– – –
– – –
–
–
–
–
+
+
+ +
+ –
+ –
+ –
+ –
+ –
– –
– +
– –
+ –
+ –
– –
–
+
–
–
–
–
– – –
+ + –
+ – +
+ – –
+ – +
+ – +
–
–
–
–
+
Staffing and Staff Roles Inconsistent expectations regarding identification and roles of helpers
+
–
+
–
–
+
Communication Hesitant to use transparent thinking (thinking out loud)
+
–
+
–
–
+
Knowledge of Protocols/Documentation Inconsistent knowledge of emergency protocols (e.g., massive transfusion)
–
–
+
–
–
–
Medications, Devices, and Equipment Medications Inconsistent or inaccurate information listed on medications Inconsistent knowledge of where all medications stored Difficulty obtaining medications because of multiple storage locations Unlabeled IV lines when several present Electronic Health Record Delayed documentation of key medical information until after emergency Balloon Tamponade No/inconsistent awareness of balloon tamponade device Inconsistent knowledge of where balloon stored No balloon available Miscellaneous Equipment Battery in emergency cordless phone did not work
* +, quality issue identified; –, quality of issue not identified; IV, intravenous.
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■ Designated stocking person and stocking routine/schedule ■ Ensured placement of equipment in room conducive to emergencies ■ Repeated simulations to test ■ Modified equipment storage based on use and easy access ■ Removal of out-of-date materials
■ Created emergency kits (e.g., postpartum hemorrhage kit) containing all related medications, syringes, and needles and taped card to kit with doses, route, and contraindications ■ Established alternative methods to obtain medication information (call the pharmacy, reference books, consultants) ■ Conducted periodic in-service on emergency equipment and medications and their storage locations and discussed expectations of stocking, including checking infrequently used emergency equipment ■ Ensured consistent labeling of IV lines ■ Standardized and communicated expectations regarding equipment and documentation of information ■ Standardized roles and expectations of helpers, including family ■ Developed examples of statements to use and practiced in simulations ■ Conducted in-services on protocol locations and how to use, practice in simulations
The Joint Commission Journal on Quality and Patient Safety ered during the debriefings of the simulation, when nurses, physicians, and midwives would discuss their impressions of what they thought they should do when called in to help, compared with the expectations of the person calling. Particularly in the case of the second nurse entering the scenario, participants mentioned not knowing what they should do and therefore waiting for instruction from the primary nurse, as well as having conflicting beliefs of the helper’s role. For example, one individual believed that the second nurse always is in charge of everything involving the second nurse’s side of the room (for example, if intravenous [IV] start supplies are on his or her side of the room, he or she starts the IV), or others believed that the second nurse is always the baby nurse. During simulation this contradictory vision of roles could be seen as inefficiency and at times caused confusion and delays. The debriefings, in which team members were brought together to talk about their experience and understandings, served as an ideal venue to problem solve mundane yet critical issues and misunderstandings efficiently. Because they were the ones uncovering the issues (through facilitated discussion) team members were engaged to find solutions and to try them out.
Discussion There is considerable controversy about the best use of simulation in clinical practice and training. Simulation, whether done locally, in simulation labs, or through mobile simulation, is expensive and resource intense. Thus, understanding the optimal use of simulation is critical. In our experience, in situ simulation offers the unique ability to probe the complexities of the clinical and interpersonal dynamics simultaneously. Conducting simulations in situ offers the unique and powerful opportunity to replicate real-life scenarios and to evaluate team and organizational performance. It also offers the greatest breadth of learning for experienced health care workers—it tests the physical environment and systems for safety, provides hands-on experience for clinicians regarding clinical conditions that are rare but reasonably likely to occur during their careers, and promotes reflection and improvements in teamwork among all clinical team members. The providers, nurses, and staff participate in clinical scenarios that likely resonate with previous experiences, and during the debriefings, they bring knowledge and reflections from these real and simulated experiences to team discussions of how to improve communication and the environment and how to respond to emergencies. Debriefings after simulation motivate team members to reflect on their practice, draw from their prior experiences, and share them as a team to understand differences in understandings to
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develop a shared model and resolve issues. More recently trained clinical professionals had experienced simulation during their education and were skeptical at first about its effectiveness and safety. For example, some of the nurses who had experienced training through simulation had not liked being observed and judged (graded). However, as fully trained professionals, they now expressed their appreciation of the opportunity that simulation provided to practice skills that they do not often use. Both experienced and inexperienced clinicians embraced the in situ training experience. The experiential learning provided through simulation proved to be a particularly effective method for clinicians to learn concepts not traditionally included in clinical training, such as strategies for effective communication and teamwork. In addition, being able to provide the program in the participants’ own clinical environment extends the value of training beyond the individual or team to improving safety and quality for the entire system. Not only was it useful to rehearse the response to a given emergency, the process of debriefing provided the unique opportunity for team members to stop and talk about a shared experience and to understand the experience and process it from other coworkers’ perspectives. Ultimately, this understanding may help the participants become better team members by discussing patterns of behavior that can be misinterpreted and by working together on a common topic to truly improve the entire process of care.40 Follow-up simulations also provided the opportunity to test systems and behavior improvements that had been put into place by each institution. The mobile in situ simulation and teamwork training approach appears to be a cost-effective mechanism to enhance and maintain skills, promote improved teamwork, identify pertinent local systems issues, and ultimately improve safety. Local hospitals may not be able to afford the cost of running a local simulation program; the equipment is expensive, the human resources required to run simulations—particularly team simulations—are considerable, and there is no central repository of evidence-based scenarios and education for easy use. If a local hospital is interested in developing a simulation program, it may want to consider partnering with other local hospitals, universities, or community colleges to share the burden of costs. Alternatively, there are numerous simulation centers around the world that offer various simulation and/or team training programs for individuals or groups, as can be found on the Web sites of simulation societies. However, the cost and inconvenience of traveling to simulation centers for training are considerable, and the effectiveness of the training, particularly
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The Joint Commission Journal on Quality and Patient Safety teamwork training, is potentially limited, because only a few members at most can leave the institution for training at any one time. Mobile simulation programs offer a potential solution for both of these issues, while also enabling the provision of in situ simulation to evaluate the degree to which local hospital systems and the physical environment promote safe, efficient, and effective care. Mobile simulation is new, so it can be challenging to find mobile simulation programs; however, often their mobile nature means they are able to travel large distances. In conclusion, studies are increasingly indicating an important role for in situ simulation in the promotion of patient safety; continuing to share lessons learned is important as the field matures. J Development and testing of the program was provided through a grant from the Agency for Healthcare Research and Quality Grant 1 U18-HS015800-02.
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See the online version of this article for
Figure 1. Simulation Algorithm for Standard Vaginal Delivery Scenario
Jeanne-Marie Guise, M.D., M.P.H., is Associate Professor, Division of Maternal Fetal Medicine, Departments of Obstetrics and Gynecology, Medical Informatics and Clinical Epidemiology, and Public Health and Preventive Medicine, and Director of the State Obstetric and Pediatric Research Collaborative (STORC) and Quality and Safety for Women’s Services for Oregon Health & Science University, Portland, Oregon. Nancy K. Lowe, Ph.D., C.N.M., is Professor and Chair, Women, Children, & Family Health, College of Nursing, University of Colorado Denver, Aurora, Colorado. Shad Deering, M.D., is a Maternal Fetal Medicine Staff and Medical Director, Andersen Simulation Center, Madigan Army Medical Center, Tacoma, Washington. Patricia O. Lewis was Senior Research Assistant, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University. Christen O’Haire, Ph.D., is Epidemiologist and Program Coordinator for the Mobile Simulation Program, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University. Lori K. Irwin, R.N., M.S., is Perinatal Clinical Nurse Specialist, Women and Children Services, Oregon Health & Science University/ Doernbecher Children’s Hospital, Portland, Oregon. Molly Blaser, R.N., M.N., is Nursing Manager, Labor & Delivery, Oregon Health & Science University. Laurie S. Wood, M.S., R.N., C.N.A.-B.C., is Director, Obstetrical Services, Maricopa Integrated Health Systems, Phoenix. Barbara G. Kanki, Ph.D., is Research Psychologist, Human-Systems Integration Division, National Aeronautics and Space Administration, Ames Research Center, Moffett Field, California. Please address correspondence to Jeanne-Marie Guise, [email protected].
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References 1. Hamilton B.E., Martin J.A., Sutton P.D.: Births: Preliminary data for 2003. Natl Vital Stat Rep 53:1–17, Nov. 23, 2004. 2. Jiang H., et al.: Care of women in U.S. hospitals, 2000. 2002 HCUP Fact Book No. 3. Agency for Healthcare Research and Quality, 2002. http://www.ahrq.gov/data/hcup/factbk3/ (last accessed Aug. 24, 2010). 3. Johanson R.B., et al.: Managing obstetric emergencies and trauma (MOET) structured skills training in Armenia, utilising models and reality based scenarios. BMC Med Educ 2:5, May 2002. 4. Baldisseri M.: Amniotic Fluid Embolism Syndrome. http://www.uptodate.com/patients/content/topic.do?topicKey= ~mJJmAFbjGf455V&selectedTitle=1%7E17&source=search_result. (last accessed Aug. 24, 2010). 5. The Joint Commission: Preventing infant death and injury during delivery. Sentinel Event Alert. Issue 30, Jul. 21, 2004. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/ sea_30.htm (last accessed Aug. 24, 2010). 6. Maternal and Child Health Research Consortium: 7th Annual Report of the Confidential Enquiry into Stillbirths and Deaths in Infancy. Jun. 2000. http://www.cmace.org.uk/getattachment/b858e5e8-862a-4121-9348b9284d02db1b/7th-Annual-Report.aspx (last accessed Aug. 24, 2010). 7. Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999. 8. U.K. Department of Health: Why Mothers Die: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, 1994–1996. Norwich, UK: The Stationary Office, 1998. 9. White A.A., et al.: Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 105:1031–1038, May 2005. 10. Singh H., et al.: Medical errors involving trainees: A study of closed malpractice claims from 5 insurers. Arch Intern Med 167:2030–2036, Oct. 2007. 11. Shojania K., et al.: Making Health Care Safer. A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43. Rockville, MD: Agency for Healthcare Research and Quality, 2001. 12. Gayman A., et al.: Implications of crew resource management training for tank crews. Paper presented at the Interservice/Industry Training System and Education Conference, Orlando, FL, 1996. 13. Grubb G., Simon R., Zeller J.: Effects of crew coordination training and evaluation methods on AH-64 attack helicopter battalion crew performance. Arlington, VA: U.S. Army Research Institute for the Behavioral and Social Sciences, 1993. 14. Salas E., et al.: Team training in the skies: Does crew resource management (CRM) training work? Hum Factors 43:641–674, Winter 2001. 15. Chopra V., et al.: Does training on an anaesthesia simulator lead to improvement in performance? Br J Anaesth 73:293–297, Sep. 1994. 16. Holzman R.S., et al.: Anesthesia crisis resource management: Real-life simulation training in operating room crises. J Clin Anesth 7:675–687, Dec. 1995. 17. Howard S.K., et al.: Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63:763–770, Sep. 1992. 18. Ballaro A., et al.: A computer generated interactive transurethral prostatic resection simulator. J Urol 162:1633–1635, Nov. 1999. 19. Bettega G., et al.: A simulator for maxillofacial surgery integrating 3D cephalometry and orthodontia. Comput Aided Surg 5(3):156–165, 2000. 20. Carrico C., Satava R.: Advanced simulation technologies for surgical education. Bull Am Coll Surg 81(7):77, 1996. 21. Chong C.K., et al.: Development of a simulator for endovascular repair of abdominal aortic aneurysms. Ann Biomed Eng 26:798–802, Sep.–Oct. 1998. 22. Derossis A.M., et al.: The effect of practice on performance in a laparoscopic simulator. Surg Endosc 12:1117–1120, Sep. 1998. 23. Fried G.M., et al.: Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator. Surg Endosc 13:1077–1081, Nov. 1999.
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The Joint Commission Journal on Quality and Patient Safety 24. Gordon J., Brown D., Armstrong E.: Can a simulated critical care encounter accelerate basic science learning among preclinical medical students? A pilot study. Simul Healthc 1:13–17, Jan. 2006. 25. Sutherland L.M., et al.: Surgical simulation: A systematic review. Ann Surg 243:291–300, Mar. 2006. 26. Szekely G., et al.: Virtual reality based surgery simulation for endoscopic gynaecology. Stud Health Technol Inform 62:351–357, 1999. 27. Advanced Life Support in Obstetrics [course syllabus]. Leawood, KS: American Academy of Family Physicians, 1993. 28. Deering S., et al.: Simulation training and resident performance of singleton vaginal breech delivery. Obstet Gynecol 107:86–89, Jan. 2006. 29. Deering S., et al.: Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol 103:1224–1228, Jun. 2004. 30. Deering S.H., Satin A.J.: Teaching infrequently used skills: Vaginal breech delivery [comment]. Obstet Gynecol 104:191–192, Jul. 2004. 31. Thomas E.J., Sexton J.B., Helmreich R.L.: Translating teamwork behaviours from aviation to healthcare: Development of behavioural markers for neonatal resuscitation. Qual Saf Health Care 13(suppl. 1):57–64, Oct. 2004. 32. Thomas E.J., et al.: Teamwork and quality during neonatal care in the delivery room. J Perinatol 26:163–169, Mar. 2006. 33. Crofts J.F., et al.: Change in knowledge of midwives and obstetricians fol-
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lowing obstetric emergency training: A randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 114:1534–1541, Dec. 2007. 34. Crofts J.F., et al.: Observations from 450 shoulder dystocia simulations: Lessons for skills training. Obstet Gynecol 112:906–912, Oct. 2008. 35. Draycott T.J., et al.: Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 112:14–20, Jul. 2008. 36. Draycott T., et al.: Does training in obstetric emergencies improve neonatal outcome? BJOG 113:177–182, Feb. 2006. 37. Smits A.K., et al.: Factors influencing cessation of pregnancy care in Oregon. Fam Med 36:490–495, Jul.–Aug. 2004. 38. Centers for Medicare & Medicaid Services (CMS): EMTALA Emergency Medical Treatment and Active Labor Act: http://www.cms.gov/EMTALA/ (last accessed Aug. 23, 2010). 39. Patterson E., Roth E., Woods D.: Facets of complexity in situated work. In Patterson E.S., Miller J. (eds.): Macrocognition Metrics and Scenarios: Design and Evaluation for Real-World Teams. Farnham, UK: Ashgate Publishing, 2010. 40. Pian-Smith M.C., et al.: Teaching residents the two-challenge rule: A simulation-based approach to improve education and patient safety. Simul Healthc 4:84–91, Summer 2009.
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Figure 1. Simulation Algorithm for Standard Vaginal Delivery Scenario Scenario Algorithm
Scenario Scene 28-year-old woman at 38 weeks. Confederate (support person) calls out and says, “The baby is coming.”
Baseline
Scenario Background Chief Complaint Baby’s coming
Visible crowning
Past Medical History No prenatal care History of quick labor with vaginal delivery at term, no complications
Delivery of infant
Social History Sister at bedside Drug Allergies None
Cord is quickly cut
Baby to warmer
Placenta delivery intact
Heart rate 120 and breathing
Evaluation Baby stable
Medications Prenatal vitamins
Mother stable
Learning Objectives Primary Technical Objectives 1. Recognize delivery and basic delivery skills 2. Demonstrate the ability to assemble adequate staff to care for mom and infant Primary Team Objectives 1. Demonstrate ability to give SBAR (form of orientation) to team 2. Closed-loop communication Secondary Technical Objectives 1. Obtained SBAR upon arrival Secondary Team Objectives 1. Role clarity 2. Directed communication 3. Effective in leading team
(continued)
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Figure 1. Simulation Algorithm for Standard Vaginal Delivery Scenario (continued) Standard Vaginal Delivery What Ifs? 1. Provider is not able to go to OR (Anesthesia has been called and is in another room) 2. Delivery 3. Assessment 4. Resolution Personnel Hot seats/Trainees Delivery Option #1 = 1 nurse; 1 doctor/midwife Option #2 = 1 nurse; 1 doctor/midwife; 1 nurse backup; 1 doctor/midwife backup Resuscitation Team Not applicable Instructor/Confederate Roles Lead debriefing instructor Associate debriefing instructor Voice of the patient +/– family member/observer Confederate nurse (new nurse trained in OB available to you to assist you) Person running mannequin
Confederates +/– significant other crying and grabbing people to help him understand what is going on Equipment/Supplies Neonate Warming bed Radiant warmer bag/mask/suction/oxygen Intubation equipment; bulb/DeLee Stethoscope Blankets Maternal Maternal delivery mannequin Delivery tray with supplies Blood pressure machine Normal fetal monitor tracing Step Vitals Remain normal Mom: blood pressure 120/60, pulse 80
Team Scenario Notes Debriefing Notes ⻬ Target fixation ⻬ Transparent thinking ⻬ Conflict resolution ⻬ Technical skills—normal spontaneous vaginal delivery ⻬ Obtain SBAR—talk about explicit versus implicit communication. ⻬ Role clarity—who was in charge? ⻬ Explore the role of event manager. ⻬ Advocating and asserting a position or corrective action ⻬ Directed communication, use of first names
Figure 1. The simulation algorithm for a standard delivery scenario is shown. Adapted from Gordon J.A.: 6 Macy Cases for Realistic Patient Simulation in Critical Care and Emergency Medicine. Harvard Medical School, 2002. http://www.harvardmedsim.org/Macy_cases.pdf (last accessed Dec. 17, 2008; no longer available). SBAR, Situation-Background-Assessment-Recommendation; OR, operating room; OB, obstetrics.
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