Deering, Shad MD; Rosen, Michael A. MA; Salas, Eduardo PhD; King, Heidi B. MS
Advances in the science and practice of obstetrics have dramatically increased the safety of childbirth. Unfortunately obstetric emergencies do still occur, and when they do, the risks for mother and child are great. Dealing effectively with obstetric emergencies requires staff with high levels of competence in technical skills as well as the teamwork skills necessary for rapid coordination of a diverse set of caregivers. However, the infrequent and critical nature of obstetric emergencies means that team members generally have few experiences with these types of clinical situations and even fewer as a consistent team.1 There are simply too few occurrences for skill to be developed and retained via on the job experience alone and, therefore, a systematic approach to training personnel for these emergencies is required. To this end, various training programs for obstetric emergencies have been developed, implemented, and some have been shown to improve clinical outcomes.2
These accomplishments are encouraging, and this article seeks to contribute to the available documentation on designing training programs for obstetric emergencies.3 Specifically, this article describes the development and implementation of the Mobile Obstetrics Emergencies Simulator (MOES) system. MOES is a comprehensive package of simulator technology, scenario-based training curriculum, and performance measurement and debriefing tools designed to build the technical and teamwork competencies necessary for staff members to effectively manage obstetric emergencies. This quality and safety improvement intervention has been implemented in 9 Labor and Delivery (L&D) units in military hospitals within the US Military Healthcare System already with another 20 currently being fielded in 2008. The MOES system has two important high-level features: (1) mobility to afford regular practice opportunities on the actual L&D ward and (2) an emphasis on teamwork as well as technical skill. These training opportunities leverage the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) teamwork training that is currently being implemented throughout the US military healthcare system.4 Additionally, the MOES system addresses the Joint Commission’s recommendations for conducting team training and clinical drills to improve perinatal outcomes.5
The specific goals of this article are to (1) clearly identify the training needs for successfully preparing staff for obstetric emergencies and (2) describe the MOES system and how it addresses these needs.
PREPARING FOR OBSTETRIC EMERGENCIES: WHAT DOES IT TAKE?
An analysis of root causes of events involving infant death or injury during delivery revealed that communication (involved in 72% of cases), staff competency (47%), and deficiencies in orientation and training programs (40%) were the most common contributing factors.5 This clearly highlights the need for the development and vigilant implementation of training programs that build and maintain technical and teamwork competence. Indeed, 3 of the first 4 Joint Commission recommendations in response to this analysis address training teamwork and technical skills. However, the Joint Commission has not provided guidance on practical implementation of this requirement. In the following sections, we provide a brief review of the available literature on training for obstetric emergencies as well as a set of training needs generated from a broader review of issues related to obstetric emergencies.
Training Needs for Obstetric Emergencies
Emergencies by nature are infrequent yet demand high levels of skilled performance to be managed effectively. This represents a type of worst case scenario in terms of developing and maintaining prepared personnel. Staff members must perform fluidly in a demanding task that they rarely perform under the conditions of acute stress and high-stakes outcomes. Performance in these situations demands high levels of both technical and teamwork skills.6
First, staff members must know how to recognize symptoms and manage patient care for obstetric emergencies and be competent in their individual roles. The exact knowledge and skills required will vary depending on the specific emergency; however, the general procedural nature of technical skills in obstetric emergencies lends itself to training via practice-based methods.7,8 There is an increasingly large literature base documenting the effectiveness of simulation-based training for technical skills in general obstetric procedures,9 and emergency procedures such as shoulder dystocia10–12 and singleton vaginal breech delivery.13 However, the need to coordinate efforts with other members of the patient care team is intertwined with technical skill proficiency. Staff members do not work in isolation, and quality of care depends on teamwork as well.
Second, effectively responding to an emergency frequently calls for the expertise of a diverse set of individuals and success relies heavily on coordination of efforts (eg, physicians, nurses, midwives, technicians).14 Effective teamwork can serve as a barrier to errors, especially in high-stress environments,15 and team training has been shown to improve a team’s ability to function under high-stress conditions.16 Additionally, simulation-based training has become a fundamental method for building teamwork skills through practice activities.17,18
In sum, preparing for obstetric emergencies requires at least 3 fundamental components: (1) building the clinical skills of staff members, (2) building teamwork skills, and (3) maintaining vigilance with these competencies in the face of skill decay and staff turnover. In the following section, we provide a brief review of some pre-existing solutions to these issues. More detailed reviews of existing training programs are available elsewhere.1,3,19,20
Existing Training for Obstetric Emergencies
A review of documented obstetric emergency training reveals 2 general types, each with associated tradeoffs. First, some training programs address all skills related to managing obstetric emergencies in one training session (whether one or several consecutive days).21,22 The Managing Obstetric Emergencies and Trauma23–25 is an example of this approach and others include the Advanced Life Support in Obstetrics26 and the Multidisciplinary Obstetric Simulated Emergency Scenarios.27 These programs tend to be multiday courses covering a number of obstetric emergencies and using lecture and practice-based training methods. This general approach has proven to be effective (ie, increased 5-minute Apgar scores and decreased the number of infants with hypoxic-ischemic encephalopathy) when staff are required to attend training annually.2
Second, there are several examples of training strategies characterized as clinical drills (also “emergency drills” or “fire drills”) available in the literature.1,28 These drills distribute learning opportunities over time. These short training experiences cover a narrower set of learning objectives, can be repeated more frequently, and take place on the actual L&D ward. This has several advantages. First, drills require less staff time to implement. Personnel do not have to travel to a dedicated training facility and consequently the issue of scheduling becomes less difficult. This allows for more frequent training to occur, which helps to ensure that newly hired staff are trained in a timely manner. Second, clinical drills on the L&D ward offer personnel opportunities to practice learned skills on the job. This is a powerful predictor of transfer of training.29,30 Third, because these drills take place on the actual L&D ward, they are useful for determining system problems that would not be detected in “off site” training.29 Although this approach has been advocated in the literature26 and by the Joint Commission, there is little guidance available on how to implement these programs in a comprehensive manner. However, as with any approach, drills have disadvantages as well. Specifically, conflicts between work duties and training can create situations where staff must balance patient care and training, possibly resulting in training sessions being interrupted.
In sum, preparing for obstetric emergencies requires a dedicated and vigilant approach to training teamwork and technical skills.
DEVELOPING AND IMPLEMENTING THE MOES
The MOES system is designed to build and maintain preparedness for obstetric emergencies. The development of the MOES system was driven by the training needs described above and four overarching goals: improving patient safety, improving teamwork and technical performance, identifying and correcting systems issues unique to each L&D unit, and meeting Joint Commission recommendations.5 To meet these goals, the MOES incorporates the following features: (1) mobility so that simulations can be run on the actual L&D unit, (2) a standardized curriculum, (3) the ability to evaluate both teamwork and technical competency, (4) incorporation of best practices in debriefing to maximize learning outcomes, (5) the capacity to track performance over time, and (6) realization of the preceding goals in a cost effective manner. This section provides details of the MOES curriculum, configuration of simulation technologies, and implementation plan.
Overview of Development Process and Timeline
The selection and configuration of existing simulator components and the design of novel simulation technology (ie, the eclampsia modification described below) as well as the development of the standardized curriculum was completed in 2006 and 2007 at the Andersen Simulation Center at Madigan Army Medical Center. In June 2007, the MOES was implemented in L&D at Madigan Army Medical Center. The first trainer session was conducted in September 2007, and included representatives from 9 L&D units from US military healthcare facilities around the world. After this training session, the MOES system was shipped to each facility for assembly and implementation. In July 2008, representatives from 20 additional L&D units were trained at the Andersen Simulation Center and each will receive the MOES system by the end of 2008.
The MOES includes a standardized, and evidence-based curriculum based on standards of care and previously published work for the entire L&D staff (ie, physicians, nurses, support personnel).10,11,13,20,23,25 This includes learning objectives for technical skills necessary for managing each targeted emergency as well as teamwork skills. Clinical competencies targeted for acquisition were based on a review of the literature. Table 1 provides an overview of the teamwork and clinical competencies for each of the targeted emergencies included in the MOES.
The MOES incorporates teamwork skills by aligning learning outcomes with TeamSTEPPS curriculum. TeamSTEPPS is a 6-hour training course designed to build evidence-based teamwork skills in a broad variety of healthcare professionals. This training is delivered via lectures, demonstrations, videos, guided discussions, and role modeling activities to all staff in the military healthcare system. Teamwork competencies targeted in TeamSTEPPS and the MOES include team structure, leadership, mutual support, situation monitoring, and communication. Although TeamSTEPPS and MOES are distinct training programs, by aligning the MOES curriculum with TeamSTEPPS, the MOES system affords opportunities for L&D staff to practice these teamwork behaviors in the context of obstetric emergencies on the unit. This essentially combines a single-session approach to training teamwork with a clinical drill approach to reinforcing teamwork behaviors on the job and training technical skills. The MOES system targets technical skills for the following obstetric emergencies: breech vaginal delivery, eclamptic seizure, postpartum hemorrhage, operative vaginal delivery, umbilical cord prolapse, shoulder dystocia, and neonatal resuscitation. The emergencies and clinical competencies included in the MOES were chosen through a review of the literature10,11,13,20,23,25 as well as with input from L&D physicians and nurses.
The curriculum includes 2 scenarios for each obstetric emergency, instructions for participants, instructions for configuring the simulator and confederate personnel for each scenario, an ideal case flow for the management of the emergency, an evidence-based didactic on the case, a technical skills measurement tool, and a guide for debriefing that includes answers to commonly raised questions and key learning points. The components of the curriculum are summarized in Table 2.
Training Delivery: Mobile Simulation
Table 3 provides an overview of the components and major costs of the MOES simulator. This includes several simulators (ie, a Noelle maternal simulator, a PEDIBlue neonatal simulator, and delivery fetuses). The birthing simulator has been modified with a reciprocating motor in place of the original birthing motor. This allows for simulation of a generalized seizure for the eclampsia scenarios. In addition to the simulators the MOES includes a monitor system, video recording system, and a Classroom Performance System (CPS) used for debriefing.
Because the MOES is designed for use on perinatal units, it is compact and portable. All MOES equipment besides the actual simulators fits into a single lockable cart that serves as a mounting platform for the video recording system and monitor system during simulation scenarios (Fig. 1).
Performance Measurement and Debrief
The effective use of feedback is a critical component of learning from practice activities31–33 and performance during a simulation must be captured in a systematic and valid manner to drive the provision of feedback during a debrief.34 To this end, the MOES includes several performance measurement and debriefing tools to facilitate the assessment of staff preparedness in terms of technical and teamwork skills and to structure the learning process. There are 2 main methods of measurement for performance included with the MOES system.
First, the CPS, shown in Figure 2, is used to structure the debrief sessions. Use of structured tools for conducting debriefs has been shown to increase the quality of debrief sessions.35 The MOES includes a modified CPS system that includes a set of questions that are viewed by the team and trainers.
Each participant and observer receives a keypad labeled and coded for their role (eg, primary physician, nurse, pediatrician). For the initial portion of the debriefing, the team uses these keypads to answer standardized questions related to their teamwork, communication, and overall performance during the simulation exercise. For each question, the responses are visually depicted on bar graphs for the group enabling the debrief facilitator to lead the group discussion using the team’s responses to bring out learning points (eg, discrepancies in perceptions of performance). Importantly, no identifying information (eg, name, position) is shown on the graphic representations of responses. Mean responses for the group are shown so that trainee responses remain anonymous during the discussion. However, trainee responses can be accessed via role at a later time for further analysis. Figure 3 illustrates a team using the CPS for a debrief session. While conducting the initial debriefing, the facilitator also uses the opportunity to review the “best practices” for the specific emergency (which are outlined in the didactic included in the curriculum). At the end of the initial debriefing, lessons learned and systems issues, if any are identified, are recorded so that they can be addressed.
Second, after the initial debriefing, the team is allowed to leave and the facilitators, usually at least 1 physician and 1 nurse, use the CPS to go through and evaluate the technical performance of the team using the standardized checklists. If there were significant mistakes that occurred with regards to the certain technical aspects, such as forceps were applied incorrectly, maneuvers for shoulder dystocia were not performed, etc., then the individuals are brought back separately and allowed to practice on the mannequin. These detailed checklists capture clinical performance and can be used to provide feedback to individuals. They were developed by Maternal Fetal Medicine physicians after review of the literature and current texts and in conjunction with experienced Labor and Delivery nursing staff. Several others have been previously described or published.9,10,13,36
The CPS system also allows for ease of tracking data over time. The output from the CPS system can be easily saved and imported into a database for evaluation of performance trends over time and for comparing performance across L&D units. Because the input devices are coded, it is possible to see if the perceptions are different between different types of staff (ie, physicians and nurses).
The MOES system also includes an integrated video system that records the simulation exercise. Afterward, the video can be used to facilitate the debriefing and bring up important points as needed.
In sum, the MOES implements a “dual debrief” strategy where team members debrief as a group immediately after the simulation session then one on one debriefs focused on improvement of individual technical skills. The initial process focuses on aspects of teamwork and technical skills relevant to all trainees involved and emphasizes the advocacy and inquiry approach32 and the second is structured with the critical action checklists for individual technical skills.9,10,13
Implementation Training and Costs
A training system that is not implemented cannot improve performance or clinical outcomes. Therefore, it was recognized early on that the MOES system must be simple enough for a relative novice to run simulations, rugged enough to stand up to the rigors of training on the actual L&D wards, and be relatively inexpensive. To this end, the following steps were taken.
First, the curriculum is presented in a standardized format that takes the proctor through the entire simulation step-by-step. It begins with the clinical scenario, addresses how to set up the room and mannequins with detailed instructions and photographs, and then includes a flow diagram of how the simulation should be conducted. There are also a list of common troubleshooting points provided as well as a DVD that shows an example of both the simulation setup and actual scenario being run. Both the debriefing and video software are explained with photos and text and an evidence-based didactic on each topic is included as well.
Second, to accompany the instruction manual, all institutions sent 2 providers, generally a physician and nurse, to a 2-day implementation course where they had the opportunity to both assemble the MOES simulator as it would be delivered and practice running the actual scenarios and conduct the debriefings. To assist them with garnering support at their institution, when they left they were also provided with a short PowerPoint presentation to be used to inform their hospital administration about the program.
Up front financial support was provided from the DoD Patient Safety Program, as the project was selected to receive funding as a Team Resource Center – Center of Excellence effort for the validation and proliferation of team coordination. Because there was no direct cost to the creation of the curriculum with the exception of the provider’s time, the entire MOES package, including mannequins, hardware and software only cost around $20,000 in its initial form. There were some small up front costs, such as the development and production of a suitable eclampsia modification that was otherwise unavailable at the time, but the cost for this modification for each unit is included in the overall price as noted. When funding for travel and shipping was included in the total cost, the final cost to send the MOES system to an institution and implement training was approximately $25,000 per site. Sustainment costs have been minimal and are anticipated to be in the neighborhood of $500 per year for each site as a birthing fetus must be replaced each year due to general wear and tear. This estimate of sustainment costs is for expendable equipment and does not include depreciation on the larger components of the system.
The preceding sections have documented the need for training team and technical competencies to prepare L&D staff for obstetric emergencies as well as the details of the MOES training system. The MOES system is one of a growing number of approaches to train staff to manage obstetric emergencies documented in the literature. Each of these training programs primarily focuses on a similar set of technical competencies, but differs in terms of training delivery methods and emphasis on teamwork. We believe that emphasizing teamwork is a critical part of the training solution. Additionally, we believe that choices of training delivery methods play a large role in the effectiveness of the system.
When comparing different methods of training delivery (eg, in situ or mobile simulation and center-based simulation), the first inclination may be to determine in some absolute terms, which method is superior. However, a more nuanced and likely more productive pursuit is an understanding of the conditions under which each method is most effective or the purposes for which each method is best suited. For example, methods of mobile simulation seek to increase access to structured learning experiences by removing practical constraints (eg, reducing travel time to simulation centers, reducing scheduling burdens). These advantages can be most salient when a unit does not have easy access to a simulation center. However, critics of this approach argue that conducing training on the unit can be ineffective because trainees must potentially split attention between training and work.
Future research is needed to generate a better understanding of the true differences between mobile simulation and center-based simulation and the equivalence or nonequivalence of training outcomes reached through each. The ultimate goal of this research would be the ability to maximize the effectiveness of each approach and to develop optimal strategies for combining the 2 methods of delivery to reach the maximum desired effect, efficient training of highly effective staff. One possible strategy for leveraging the strengths between the two could be to focus on the acquisition of entirely new knowledge and skills in a focused session at a simulation center, and use of in situ simulation to reinforce these skills in the context of work to improve transfer. For example, the MOES system uses mobile simulation to reinforce teamwork behaviors acquired in a lecture-based training program (TeamSTEPPS).
Future evaluation plans for the MOES system will seek to contribute to a better understanding of the effectiveness of mobile simulation. As part of the process-improvement plan for the MOES program, pre- and postimplementation surveys will be administered to the L&D personnel (physicians and nurses) at the L&D wards in the military healthcare system where the MOES system is being implemented. This survey will help to gauge the impact of MOES implementation on perceptions of individual competency dealing with obstetric emergencies, perceptions of overall unit preparedness for managing these emergencies, and perceptions of teamwork on the unit. Additionally, longitudinal data capture via the MOES performance measurement tools will be used to evaluate the impact of the training program on team and clinical performance over time.
Teamwork and technical skills are the foundation of the effective management of obstetric emergencies. The MOES strategy of a standardized curriculum, alignment with pre-existing TeamSTEPPS teamwork training, and mobility so that training can be embedded in the actual work environment is designed to develop these skills in staff members and to maintain the staff’s preparedness over time. The need for this type of training is clearly documented in the existing literature. The MOES system uses a unique configuration of training tools to meet these needs. By using this system, we hope to be able to provide a better means for assessing and improving preparedness for obstetric emergencies and plan to continue to evaluate and report on training and clinical outcomes as the program expands to another 20 institutions by the end of 2008.
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