Entrenamiento de equipos interdisciplinares en urgencias obstétricas mediante simulación clínica

Objectives

To describe the healthcare team training in obstetric emergencies using clinical simulation with an interdisciplinary approach, developed at the Hospital virtual Valdecilla.

Material and methods

The program was aimed at health professionals involved in emergency obstetric care (obstetricians and gynecologists, anesthesiologists, intensivists and midwives). A working team was established to define the objectives, design the scenarios, and coordinate the completion of each course. Two simulation rooms were available with patient simulators, control rooms and audiovisual recording systems, an analysis room, a multipurpose classroom, and diverse medical and surgical equipment. To analyze the results of the program, the participants completed an evaluation survey.

Results

A total of 30 members of clinical teams underwent training in the clinical entities most frequently involved in cases of maternal mortality (postpartum hemorrhage, amniotic fluid embolism and eclampsia), selected from the results of a survey of maternal death mailed to 69 Spanish hospitals. Each course consisted of three clinical cases performed in the operating room, postpartum and birthing room, followed by a debriefing session. Participants rated the courses as highly useful, highlighted the opportunity provided by clinical simulation to practice without risk and to train teamwork skills, and would recommend their peers to undergo the same training.

Conclusions

Training of healthcare teams in obstetric emergencies using simulation with an interdisciplinary approach provides safe and effective practice of diagnostic and treatment algorithms, as well as of communication and teamwork skills, before these situations are met in daily practice.     

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

ObjectiveTo provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.Target populationProviders working to improve health care for Canadian women and their families; patients and their families.OutcomesSimulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.Benefits, Harms, and CostsThis modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.EvidenceArticles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords “simulation” and “simulator.” The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceAll health care professionals working to improve Canadian women’s health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.Recommendations

• 1.Health care professionals in obstetrics and gynaecology should understand the value of both in situ and off-site simulation as a tool for education, patient safety, and quality improvement at both the team and individual levels (strong, moderate).
• 2.Health care professionals in obstetrics and gynaecology should be aware of the overall cost reduction associated with the use of simulation (strong, moderate).
• 3.Stakeholders at all levels must commit to an ongoing simulation program, including identifying, training, and supporting simulation advocates, as well as securing adequate funding. This approach leads not only to organizational readiness but also to quality improvement and positive culture change (strong, moderate).
• 4.Providers of obstetrical and gynaecological care should be familiar with key simulation modalities and principles of how to advance knowledge using simulation (conditional, low).
• 5.Purposeful simulation activities must be based on local needs assessments and knowledge gaps (conditional, low).
• 6.Interprofessional/interdisciplinary teams should participate in the design, implementation, and evaluation of team training and in situ simulation programs (strong, high).
• 7.Debriefing must be promoted as a fundamental component of the experiential learning process. Team debriefing/peer debriefing with a written guide can be as effective (as an alternative) as expert debriefing (strong, high).
• 8.Psychological safety must be established for all personnel within the simulation and the debriefing (strong, moderate).
• 9.Program evaluation, a system to measure the efficacy of a learning activity, must be included in the planning of simulation activities to assess whether the targeted outcomes of the program were achieved (strong, moderate).
• 10.Simulation-based activities should be designed in a culturally sensitive and socially responsible way, similar to all other aspects of health professionals’ education (strong, low).

     

Implementing Obstetrics Quality Improvement,Driven by Medico-legal Risk,is Associated With Improved Workplace Culture

ObjectiveThis study implemented a quality improvement program based on knowledge of medico-legal risk in obstetrics and sought to evaluate the impact of this program on workplace culture.MethodsThe study conducted needs assessments with front-line providers working in the obstetrical unit of the Queensway Carleton Hospital, an urban community hospital in Ottawa, Ontario, and included the safety, communication, operational reliability, and engagement (SCORE) survey. The study investigators delivered training in quality improvement science and co-developed three projects that were based on their alignment with local needs and aggregate medico-legal risk data: an organized team response to the need for an immediate cesarean section, a protocol for managing patients who present at term with pre-labour rupture of membranes, and regular morning team briefings. Outcome measures were determined for each project from a quality improvement indicator framework, and coaching was provided to project leads. Participants completed the SCORE survey and a program effectiveness tool after the intervention.ResultsThe majority of participants (75.2% of 153 pre-intervention and 63.1% of 157 post-intervention participants) completed the SCORE surveys. Post-intervention improvements were found in teamwork, learning environment, and safety climate, whereas levels of provider burnout remained high. Program effectiveness was highly rated, and most projects showed qualitative improvements.ConclusionThis study showed positive workplace culture change associated with the quality improvement intervention. Lessons learned from the implementation of this program can inform future quality improvement initiatives.     

Experiences of Family Physicians Who Practise Primary Care Obstetrics in Groups

ObjectiveThe purpose of this study was to explore the experiences of family physicians in primary care obstetrical groups.MethodsUsing a qualitative approach, in-depth interviews were conducted with 12 Edmonton family physicians who participated in primary care obstetrical groups. Experiences with respect to several aspects of group obstetrical practice were examined including advantages and challenges of primary care obstetrical groups, provision of patient care by a group, fit with other work commitments, and sustainability of the groups. Study data were audiotaped and transcribed verbatim. Independent and team analysis was iterative and interpretive.ResultsPrimary care obstetrical groups were found to preserve a family physician’s enjoyment of obstetrics and allowed for continuity of care. They afforded work-life balance, allowed for collaboration, and provided support and a social network for group members Such groups were found to facilitate short-term family physician absences, although long-term absences (such as maternity leaves) were considered challenging. Participants described conflict within primary care obstetrical groups and considered sustainability to be a challenge.ConclusionFamily physicians’ continued involvement in obstetrics could be facilitated by their participation in primary care obstetrical groups.     

Self-perceived impact of simulation-based training on the management of real-life obstetrical emergencies

Objective

To evaluate the self-perceived impact of attending a simulation-based training course on the management of real-life obstetrical emergencies.

Study design

A prospective follow-up study was conducted. Obstetric nurses and obstetricians (n = 54) from a tertiary care university hospital participated in a simulation-based training course for the management of four obstetric emergencies. One year after the last session of the course, participants were asked to complete a questionnaire evaluating the self-perceived impact it had on their knowledge, technical skills, and teamwork skills during experienced real-life situations. A five-point Likert grading scale was used. The χ² test with one degree of freedom or the Fisher's exact test were used to compare groups of participants. The t-test for independent samples was used to compare mean scores between groups.

Results

A total of 46 healthcare professionals answered the questionnaire: 27 obstetricians and 19 obstetric nurses. Of these, 87% perceived an improvement (scores 4 or 5) in their knowledge and skills during real emergencies. Obstetric nurses expressed a significantly higher improvement than obstetricians in their ability to diagnose or be aware of obstetrical emergencies (p = 0.002), in their technical skills (p = 0.024), and in their ability to deal with teamwork related issues (p = 0.005). Participants who had experienced in real-life situations all four simulated scenarios rated the impact of training significantly higher than others (p = 0.049), and also reported a better improvement in their knowledge of management guidelines (p = 0.006).

Conclusions

Healthcare professionals who participated in a simulation-based training course in obstetrical emergencies perceived a substantial improvement in their knowledge and skills when witnessing real-life emergencies. Improvements seem to be particularly relevant for obstetric nurses and for those who witness all trained obstetrical emergencies.     

急救模拟培训在产科临床实践中的意义

产科急救模拟培训可提高产科医务工作者处理复杂危急重症的临床综合技能、增强临床处理信心、提高团队沟通能力,有效降低相关不良母儿结局的发生,但培训效果会随着间隔时间延长逐渐减弱。因此,强调急救模拟培训在产科危急重症处理(肩难产、脐带脱垂、产后出血、子痫)中的运用,并要注重定期、重复培训。     

Family Violence and Maternal Mortality in the South Asian Community: The Role of Obstetrical Care Providers

ObjectiveSouth Asian women face multiple barriers to accessing information and support if they are experiencing spousal abuse. We conducted a study among South Asian women in Surrey, British Columbia, to define a role for obstetrical care providers in assisting women who experience family violence.MethodsSouth Asian women survivors of abuse participated with representatives of family and victim services agencies in a workshop to identify key opportunities for violence prevention and intervention by obstetrical care providers. Participants grouped issues affecting women’s vulnerability to violence into four themes and identified strategies to address them.ResultsThemes focused on cultural issues, services and supports, education and prevention, and policy and advocacy. Participants highlighted challenges posed by the patriarchal nature of their culture and, for many families, by recent immigration. They emphasized the importance of routine assessment for family violence by obstetrical care providers and stressed the need to treat the entire family, not just the identified victim. They focused on the role of the caregiver as a conduit of information about social services and other resources. Community-level interventions to address abuse were endorsed, including the use of lay media to deliver key messages about health and safety.ConclusionPregnancy offers caregivers an opportunity to be advocates and to provide information and referrals for women in the South Asian community who may be at risk of violence. Obstetrical caregivers may be an important influence in protecting women from lethal harm.     

PRONTO training for obstetric and neonatal emergencies in Mexico

ObjectiveTo evaluate the acceptability, feasibility, rating, and potential impact of PRONTO, a low-tech and high-fidelity simulation-based training for obstetric and neonatal emergencies and teamwork using the PartoPants low-cost birth simulator.MethodsA pilot project was conducted from September 21, 2009, to April 9, 2010, to train interprofessional teams from 5 community hospitals in the states of Mexico and Chiapas. Module I (teamwork, neonatal resuscitation, and obstetric hemorrhage) was followed 3 months later by module II (dystocia and pre-eclampsia/eclampsia) and an evaluation. Four elements were assessed: acceptability; feasibility and rating; institutional goal achievement; teamwork improvement; and knowledge and self-efficacy.ResultsThe program was rated highly both by trainees and by non-trainees who completed a survey and interview. Hospital goals identified by participants in the module I strategic-planning sessions were achieved for 65% of goals in 3 months. Teamwork, knowledge, and self-efficacy scores improved.ConclusionPRONTO brings simulation training to low-resource settings and can empower interprofessional teams to respond more effectively within their institutional limitations to emergencies involving women and newborns. Further study is warranted to evaluate the potential impact of the program on obstetric and neonatal outcome.     

A Measurement Tool to Assess Culture Change Regarding Patient Safety in Hospital Obstetrical Units

ObjectiveClinical error in acute care hospitals can only be addressed by developing a culture of safety. We sought to develop a cultural assessment survey (CAS) to assess patient safety culture change in obstetrical units.MethodsInterview prompts and a preliminary questionnaire were developed through a literature review of patient safety and “high reliability organizations,” followed by interviews with members of the Managing Obstetrical Risk Efficiently (MORE^OB) Program of the Society of Obstetricians and Gynaecologists of Canada. Three hundred preliminary questionnaires were mailed, and 21 interviews and 9 focus groups were conducted with the staff of 11 hospital sites participating in the program. To pilot test the CAS, 350 surveys were mailed to staff in participating hospitals, and interviews were conducted with seven nurses and five physicians who had completed the survey. Reliability analysis was conducted on four units that completed the CAS prior to and following the implementation of the first MORE^OB module.ResultsNineteen values and 105 behaviours, practices, and perceptions relating to patient safety were identified and included in the preliminary questionnaire, of which 143 of 300 (47.4%) were returned. Among the 220 cultural assessment surveys returned (62.9%), six cultural scales emerged: (1) patient safety as everyone’s priority; (2) teamwork; (3) valuing individuals; (4) open communication; (5) learning; and (6) empowering individuals. The reliability analysis found all six scales to have internal reliability (Cronbach alpha), ranging from 0.72 (open communication) to 0.84 (valuing individuals).ConclusionThe CAS developed for this study may enable obstetrical units to assess change in patient safety culture.     

情景模拟培训在医学教育中的价值

情景模拟培训在医学教育中具有模拟真实性、无医疗风险、个体化教育、客观规范化、可重复性等优势。在产科急重症抢救方面使用模拟训练,可提高团队成员应急能力和沟通协作能力,从而最大限度地改善医疗结局,保障医疗安全。     

Emergency Birth Hybrid Simulation with Standardized Patients in Midwifery Education: Implementation and Evaluation

Structured simulations have become a critical part of health professions education at every level, particularly for high‐risk, low‐incidence scenarios. This article describes the implementation and evaluation of a hybrid simulation of emergency birth situations in a graduate midwifery program. In the fall of 2011 and spring of 2012, nurse‐midwifery students twice participated in 2 simulated emergencies—shoulder dystocia and postpartum hemorrhage—using hybrid simulation (a standardized patient paired with a birth task trainer). Students found the simulations to be realistic. The use of best practices (ie, repetitive practice, team learning, small group debriefing, and large group debriefing) enhanced the quality of the simulation experience and the learners’ reflection about their professional skills, strengths, weaknesses, and confidence in managing these 2 obstetric emergencies. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

Interdisciplinary Skills Review Program to Improve Team Responses During Postpartum Hemorrhage

Objective

To develop an interdisciplinary, interactive, skills review program to improve team responses during a postpartum hemorrhage (PPH).

The use of simulation to teach clinical skills in obstetrics

Obstetrical practice demands sensitivity, clinical skill, and acumen. Obstetrical emergencies are rare occurrences and are most appropriately dealt with by experienced staff. Simulation provides an opportunity to gain this experience without patient risk and furthermore builds confidence and satisfaction amongst learners. There is an abundance of evidence to show the effectiveness of simulation training. Simulation has been demonstrated to reduce errors, increase knowledge, skills, communication and team working, and improve perinatal outcomes. Further research to measure the effect of training to identify what works, where and at what cost is needed. We explore the evidence for the use of simulation-based training across a broad range of obstetrical emergencies, promote collaboration amongst disciplines and discuss the formal introduction of simulation training into a curriculum. Reducing preventable harm in obstetrics is a priority for families and society at large and this article endeavors to highlight the role that simulation has to play.     

Outcomes of the Introduction of the MOREOB Continuing Education Program in Alberta

ObjectiveIn 2004, the three-module, three-year long patient safety program, Managing Obstetrical Risk Efficiently (MORE^OB), was introduced to all clinicians providing obstetrical services in Alberta. We report on an outcomes evaluation of this initiative.MethodsProvincial hospital discharge abstracts for each mother and infant were obtained from 2003 through 2008. A pre–post design with a multivariate analysis was conducted for each relevant maternal and fetal outcome.ResultsFor maternal outcomes, third- and fourth-degree tears and length of stay were significantly decreased. For newborn outcomes, severe morbidity was significantly reduced.ConclusionThe MORE^OB program was associated with improvement in selected maternal and fetal health outcome indicators. When a patient safety program is introduced as an intensive, long-term continuing education and quality improvement initiative, health outcomes can be significantly impacted.     

Training health workers to prevent and manage post-partum haemorrhage (PPH)

Post-partum haemorrhage (PPH) is the second greatest direct cause of maternal death in the United Kingdom, and rates of PPH continue to increase despite advances in clinical care. Training workers to manage PPH involves improvement of technical and non-technical skills in the context of a multidisciplinary team (MDT). Management of PPH should begin in the antenatal period, with identification of high-risk women and referral for multispecialty input. Training for the acute management of PPH should involve all members of the labour ward team and beyond, including haematology and non-clinical staff. Simulation-based training, didactic teaching and hybrid obstetric emergency courses are current options for training workers. Non-technical skills should also be taught, including specific training on communication, leadership, situational awareness and team-working skills. Improving management of obstetric emergencies requires thorough antenatal and intra-partum risk assessment, optimising knowledge and non-technical skills of individual members of the team, improving collaboration of the MDT, better simulation training and adjusting local infrastructure.     

Obstetric simulation for a pandemic

ObjectiveIn the middle of the COVID-19 pandemic, guidelines and recommendations are rapidly evolving. Providers strive to provide safe high-quality care for their patients in the already high-risk specialty of Obstetrics while also considering the risk that this virus adds to their patients and themselves. From other pandemics, evidence exists that simulation is the most effective way to prepare teams, build understanding and confidence, and increase patient and provider safety.FindingPracticing in-situ multidisciplinary simulations in the hospital setting has illustrated key opportunities for improvement that should be considered when caring for a patient with possible COVID-19.ConclusionIn the current COVID-19 pandemic, simulating obstetrical patient care from presentation to the hospital triage through postpartum care can prepare teams for even the most complicated patients while increasing their ability to protect themselves and their patients.     

Enhancing Postgraduate Training in Pediatric and Adolescent Gynecology: Evaluation of an Advanced Pelvic Simulation Session

Study ObjectiveTo describe and evaluate a Canadian simulation session designed to teach pediatric and adolescent gynecology (PAG) history taking, examination and operative skills, and an approach to the child and adolescent.DesignObstetrics and gynecology residents in a single academic center participated in a PAG simulation session and rated their gain in knowledge on 6 aspects of PAG care.SettingAcademic half-day at the University of Ottawa Skills and Simulation Centre.ParticipantsTwenty-four Obstetrics/Gynecology residents at the University of Ottawa.InterventionsParticipants completed 4 stations teaching PAG-appropriate history taking, genital examination, Tanner staging, vaginal sampling and flushing, hymenectomy, vaginoscopy, laparoscopic adnexal detorsion, and approach to the child/adolescent. Advanced pelvic models were used for procedure specific stations. Participants completed an anonymous evaluation form at the end of the session.Main Outcome MeasureSelf-perceived increase in knowledge and PAG specific skills after the simulation session.ResultsTwenty-four residents completed the simulation session and post-session evaluation. All residents (100%) agreed that they had gained knowledge in PAG history taking, examination techniques, office procedures, operative skills, approach to child, and approach to the adolescent. Qualitative feedback stressed the excellence of instruction, interaction, immediate feedback, and hands-on experience. All residents (100%) stated the PAG simulation session should continue.ConclusionsThis advanced PAG simulation session increased resident self-perceived knowledge. Other obstetrics/gynecology training programs should consider implementing advanced PAG simulation sessions to increase resident knowledge and confidence in delivering care to the pediatric/adolescent patient.     

Optimization of competency in obstetrical emergencies: a role for simulation training

Purpose

In obstetrical emergency situations, optimal management requires the immediate coordinated actions of a multi-disciplinary and multi-professional team. This study investigated the influence of simulation training on four specific skills: self-confidence, handling of emergency situation, knowledge of algorithms and team communication.

Methods

Clinical algorithms were first presented to the participants. Training for six emergency situations (shoulder dystocia, postpartum haemorrhage, pre-eclampsia, maternal basic life support, neonatal resuscitation and operative vaginal birth) was performed using high- and low-fidelity simulation mannequins. General impression of the simulation training and the four above-mentioned skills were evaluated anonymously through a self-assessment questionnaire with a five-point Likert scale immediately after the training and 3 months later.

Results

From November 2010 to March 2012, 168 participants, distributed over six one-day courses, took part in the training. 156 participants returned the questionnaire directly after the course (92.9 %). The questionnaire return rate after 3 months was 36.3 %. The participants gave higher Likert scale answers for the questions on the four specific skills after 3 months compared to immediately after the course. The improvement was statistically significant (p ≤ 0.05) except for the question regarding team communication.

Conclusion

Implementation of simulation training strengthens the professional competency.