沙盘模拟在产科专科培训的应用初探

目的探讨沙盘模拟培训在产科专科培训应用中的可行性和有效性。 方法培训班以沙盘模拟形式对学员进行产科急危重症与助产技术培训，采用"沙盘推演—学员操作—导师点评—导师演示"的培训模式，内容包括子痫、产后出血、肩难产、阴道助产和新生儿窒息复苏。选取200名学员为研究对象，并随机分成5个团队，培训前后对学员进行理论知识和操作技能考核，根据考核标准由导师组进行打分，并对每个团队的抢救流程进行考核评分。同时培训前后发放调查问卷对培训课程进行反馈。 结果经培训后，学员的理论考核成绩(91.1±14.5)分较培训前(75.6±24.0)分明显提高，差异有统计学意义(P<0.05)。各操作模块考核前后成绩分别为：子痫(73.7±5.6)分与(90.6±3.9)分，产后出血(71.2±8.7)分与(88.9±4.8)分，阴道助产(70.1±7.9)分与(90.0±4.8)分，肩难产(74.6±5.7)分与(91.5±2.3)分，新生儿窒息(73.2±4.7)分与(91.2±2.5)分，培训后成绩明显提高，差异有统计学意义(P<0.05)。团队考核的Topsis分析结果显示，团队3在多项指标上都是最优秀的，综合排名第一名，尤其是方案设计。团队5在临床技能表现突出，在团队配合和患者沟通方面做得也比较好。团队2和团队4各项指标都表现不足。 结论团队3大部分成员来自三甲医院，经常参加产科模拟培训班，因此总体素质较高，而团队2和团队4来自基层医院的成员居多，接受培训的次数较少，因此成绩偏弱，尤其在流程、沟通和团队配合等方面，还需要加强培训。沙盘模拟培训作为一种新型的体验式培训模式，具有创新性、互动性、趣味性，并具有实战性，在产科急危重症专科培训中具有较大的发展前景。     

Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training

Objectives  To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training.
Design  A prospective randomised controlled trial.
Setting  Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK.
Population  Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied.
Methods  Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre.
Main outcome measures  Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention.
Results  There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1–23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training ( P = 0.965).
Conclusions  Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.     

Teamwork in obstetric critical care

Whether seeing a patient in the ambulatory clinic environment, performing a delivery or managing a critically ill patient, obstetric care is a team activity. Failures in teamwork and communication are among the leading causes of adverse obstetric events, accounting for over 70% of sentinel events according to the Joint Commission. Effective, efficient and safe care requires good teamwork. Although nurses, doctors and healthcare staff who work in critical care environments are extremely well trained and competent medically, they have not traditionally been trained in how to work well as part of a team. Given the complexity and acuity of critical care medicine, which often relies on more than one medical team, teamwork skills are essential. This chapter discusses the history and importance of teamwork in high-reliability fields, reviews key concepts and skills in teamwork, and discusses approaches to training and working in teams.     

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.     

Clinical skills training in obstetrics - a descriptive survey of current practice in Denmark

The Danish National Board of Health has recommended that labor wards establish regular obstetric emergency skills training programs. The aim of this study was to describe current practice in Denmark. A questionnaire was sent to all obstetric departments in Denmark in 2008. All responded. Simulation-based training was conducted in 26/28 obstetrical departments. Settings for the training programs were mainly local. Training was provided for shoulder dystocia, postpartum bleeding and basic neonatal resuscitation in almost all the departments, but was not organized in a uniform way. Neither the program itself nor the participants' performance was evaluated in a structured or validated way. Obstetric emergency skills training is being actively conducted in the majority of the Danish labor wards. However, it still remains a challenge to ensure the uniform organization and evaluation of the current training programs. Development of validated national or international standards for an obstetric training program should be a future aim.     

Mode of Delivery: Development and Implementation of an Obstetrical In Situ Simulation Program

ObjectiveSimulation is increasingly valued as a learning tool in obstetrical practice. In situ simulation assesses the hands-on and critical thinking skills of a health care team within their clinical setting. We aimed to create an in situ simulation program to promote skills acquisition, enhance teamwork, and identify system limitations.MethodsKey obstetrical emergencies were identified through a needs assessment. In situ simulations were developed to address these clinical presentations. During simulations, organizers and participants identified latent safety threats. Medical management was evaluated through comprehensive emergency-specific checklists. Leadership attitudes were assessed using the modified Perinatal Emergency Team Response Assessment tool. Following each simulation, team members were debriefed, and qualitative and quantitative feedback was solicited and aggregated by specialty and discipline.ResultsSimulations were conducted monthly at two academic centers over 14 months. Participation was interdisciplinary, including learners, staff physicians, nursing, and allied health team members from the departments of obstetrics, anesthesia, emergency medicine, and neonatology. Participants reported their involvement was enjoyable. Participants reported improvements in communication skills, content knowledge, and procedural knowledge. Participants favourably rated the spontaneity of simulations, clinically relevant scenarios, safe environment, and use of realistic equipment. Latent safety threats, related to equipment, medication, personnel, resources, and technical skills, were identified.ConclusionWe present the successful implementation of a comprehensive in situ simulation program. In situ simulation allows for deliberate practice of obstetrical emergencies and promotes a culture of patient safety. Lessons learned provide valuable data to identify limitations within our current practices and inform future policy change.     

Effectiveness of team training in managing shoulder dystocia: a retrospective study

Objectives: To evaluate the effectiveness of simulation team training for the management of shoulder dystocia. Primary outcome measures were the number of reported cases of shoulder dystocia, as well as fetal injury that occurred from it. Secondary outcome is documentation of manoeuvres used to alleviate shoulder dystocia.

Methods: Retrospective cohort study in a teaching hospital in the Netherlands, in a 38 month period before and after implementation of team training.

Results: We compared 3492 term vaginal cephalic deliveries with 3496 deliveries before and after team training. Incidence of shoulder dystocia increased from 51 to 90 cases (RR 1.8 (95% CI: 1.3–2.5)). Fetal injury occurred in 16 and eight cases, respectively (RR 0.50 (95% CI: 0.21–1.2)). Before team training started, the all-fours manoeuvre was never used, while after team training it was used in 41 of 90 cases (45%). Proper documentation of all manoeuvres used to alleviate shoulder dystocia significantly increased after team training (RR 1.6 (95% CI: 1.05–2.5)).

Conclusions: Simulation team training increased the frequency of shoulder dystocia, facilitated implementation of the all-fours technique, improved documentation of delivery notes and may have a beneficial effect on the number of children injured due to shoulder dystocia.     

Shoulder dystocia: Simulation and a team-centered protocol

Shoulder dystocia is an obstetric emergency that has been reported to occur in 0.2–3% of all vaginal deliveries. Several characteristics of shoulder dystocia make it a particular challenge to manage effectively. It is relatively infrequent, the diagnosis cannot be made according to a single objective criterion that can be recognized to exist by all members of the care team who are present, it is unpredictable, and there is the need for coordinated actions of all members of the health care team who have come together on the day of the delivery and may not have worked together before or specifically during a shoulder dystocia. In general, there is evidence from different medical disciplines that checklists/protocols and simulation may be used to enhance team performance. There is also some evidence, albeit limited, that such techniques may be used to improve shoulder dystocia outcomes.     

The active components of effective training in obstetric emergencies

Confidential enquiries into poor perinatal outcomes have identified deficiencies in team working as a common factor and have recommended team training in the management of obstetric emergencies. Isolated aviation-based team training programmes have not been associated with improved perinatal outcomes when applied to labour ward settings, whereas obstetric-specific training interventions with integrated teamwork have been associated with clinical improvements. This commentary reviews obstetric emergency training programmes from hospitals that have demonstrated improved outcomes to determine the active components of effective training. The common features identified were: institution-level incentives to train; multi-professional training of all staff in their units; teamwork training integrated with clinical teaching and use of high fidelity simulation models. Local training also appeared to facilitate self-directed infrastructural change.     

Impact of simulation and team training on postpartum hemorrhage management in non-academic centers

Objective: Prompt recognition and response to postpartum hemorrhage (PPH) are vital in preventing maternal morbidity and mortality. We conducted a multi-center study to evaluate in situ simulation and team training for PPH among experienced clinical teams in non-academic hospitals in urban and rural communities.

Methods: A longitudinal intervention study was performed in six Oregon community hospitals. All teams responded to an in situ simulated delivery and postpartum hemorrhage using trained actors and an obstetric birthing simulator, followed by a debriefing and training session. The simulation scenario was then repeated in 9–12?months. All sessions were digitally video recorded and independently reviewed by two obstetricians using a structured evaluation form. PPH management including clinical response times were compared before and after team training using Student’s paired t-test and McNemar’s test.

Results: Twenty-two teams completed paired case simulations. Team training significantly improved response times in the management of PPH, including the recognition of PPH, time to administer first medication, performance of uterine massage and time to administer second medication. Medical management (use of three indicated medications) improved after training from 27.3% to 63.6%, p?=?0.01.

Conclusions: Simulation and team training significantly improved postpartum hemorrhage response times among clinically experienced community labor and delivery teams.     

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.     

Shoulder dystocia: prevention and management

Knowledge of the maneuvers used for the alleviation of shoulder dystocia is relevant not only for obstetric residents and attending house staff but also for family practitioners, nurses, and nurse midwives. The performance of shoulder dystocia "drills" can be helpful not only to coordinate a teamwork approach to this obstetric emergency but also to provide an opportunity to practice the maneuvers. Shoulder dystocia continues to represent an immense area of clinical interest because it typically occurs without prediction. All patients in labor should be considered at risk for the development of shoulder dystocia.     

Outcomes from a labor and delivery team training program with simulation component

We evaluated the implementation of a labor and delivery unit team training program that included didactic sessions and simulation training with an active clinical unit. Over an 18-month follow-up time period, our team training program showed improvements in patient outcomes as well as in perceptions of patient safety including the dimensions of teamwork and communication.     

Improving resident competency in the management of shoulder dystocia with simulation training

OBJECTIVE: To determine whether a simulation training scenario improves resident competency in the management of shoulder dystocia. METHODS: Residents from 2 training programs participated in this study. The residents were block-randomized by year-group to a training session on shoulder dystocia management that used an obstetric birthing simulator or to a control group with no specific training. Trained residents and control subjects were subsequently tested on a standardized shoulder dystocia scenario, and the encounters were digitally recorded. A physician grader from an external institution then graded and rated the resident's performance with a standardized evaluation sheet. Statistical analysis included the Student t test, chi(2), and regression analysis, as appropriate. RESULTS: Trained residents had significantly higher scores in all evaluation categories, including timelines of their interventions, performance of maneuvers, and overall performance. They also performed the delivery in a shorter time than control subjects (61 versus 146 seconds, P =.003). CONCLUSION: Training with a simulation-training scenario improved resident performance in the management of shoulder dystocia. LEVEL OF EVIDENCE: I     

Recurrent obstetric management mistakes identified by simulation

OBJECTIVE: To develop a simulation-based curricular unit for labor and delivery teams involved in obstetric emergencies to detect and address common mistakes. METHODS: A simulation-based curricular unit for hands-on training of four obstetric emergency scenarios was developed using high-tech mannequins and low-tech simulators. The scenarios were eclamptic seizure, postpartum hemorrhage, shoulder dystocia, and breech extraction. The obstetric teams consisted of at least one resident and two midwives. Checklists of actions expected from the teams were handed out to the course's tutors who observed the "event." All sessions were videotaped and then reviewed and analyzed by the trainees themselves, who were guided by two experienced tutors. We identified the most commonly occurring mistakes by summing up checklists and by watching the recorded sessions. RESULTS: Between February 2004 and April 2006, 60 residents in obstetrics and gynecology and 88 midwives underwent the simulation-based course. Forty-two labor and delivery teams completed all four sessions. The most common management errors were delay in transporting the bleeding patient to the operating room (82%), unfamiliarity with prostaglandin administration to reverse uterine atony (82%), poor cardiopulmonary resuscitation techniques (80%), inadequate documentation of shoulder dystocia (80%), delayed administration of blood products to reverse consumption coagulopathy (66%), and inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%). Eighteen trainees were invited for repeated sessions at least 6 months after the first training day, and their scores were significantly higher in the latter sessions (79.4+/-4.3 versus 70+/-5.3 for the second and first simulated eclampsia sessions). CONCLUSION: A curricular unit based on simulation of obstetric emergencies can identify pitfalls of management in labor and delivery rooms that need to be addressed.     

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.     

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.     

产科模拟人在子痫急救演练中的运用

子痫属于产科危急重症,急救处理恰当与否对母胎预后有极大影响。但子痫在平时临床工作中较为少见,从而导致医护人员对其急救方法掌握不足。采用产科模拟人进行子痫急救演练具有真实、可控、可重复等特点,可将一般急诊处理、控制抽搐、控制血压、适时终止妊娠等子痫急救方案通过病例编写以模拟真实急救,让参演者更好地进入各自角色完成演练。演练目的除了提升参演者的急救技能外,还注重提升团队的协作能力。通过应用产科模拟人进行子痫演练,参演者能在短时间内最大程度提升个人急救技能及团队协作意识。     

Staying alive—training with anaesthetists

An effective working relationship between obstetricians and anaesthetists is crucial for patient safety in maternity care. Anaesthetists' skills and scope of clinical practice complement those of obstetricians, particularly during obstetric emergencies. Anaesthetists also bring expertise in resuscitation, critical care, and a training programme that is underpinned by non-technical as well as technical skills. Through training together, obstetricians and anaesthetists can help plug one another's knowledge gaps, identify each other's blind spots, aid mutual decision-making, and share relevant national guidance between specialties. Training also aids the development of a shared mental model, which contributes to improved teamwork. To be effective, this training should involve the whole team, be conducted in-house, be used to tackle local as well as national priorities, and be repeated regularly.