Contemporary risk management and patient safety staff training focuses on improving the clinical and communicational skills of inexperienced health care providers which has led to the emergence of a plethora of educational programs and workshops to supplement textbook knowledge.1,2 There are two major obstacles in providing hands-on clinical experience in emergency medicine. First, life-threatening situations invariably require intervention by the most skilled caregivers on the scene, precluding any opportunity for less experienced personnel to take full charge in such extreme scenarios. Second, uncommon conditions requiring special skills are by definition infrequent.3,4 A simulation-based drill provides an excellent solution to these limitations because it allows repeated practice and acquisition of skills for conditions that are not amenable to traditional bedside teaching.5–7
The efficacy of simulation training was first demonstrated in aviation by exposing young pilots to simulated extreme weather conditions and various critical mishaps, recording their actions and guiding them in correcting their errors by reviewing the recorded events together with an experienced pilot.8,9 The abrupt decrease in disastrous air accidents in the mid-1990s among air forces of western nations is attributable to the utility of simulation.10 Medical emergencies also deal with critical situations that require prompt and appropriate action to avoid a catastrophe but are impossible to practice without risk. Simulation-based teaching soon became very popular in anesthesiology and trauma, and its beneficial effects on the performance of young residents are well established.11–14
Life-threatening obstetric emergencies are, fortunately, uncommon but require skill and prompt action to avoid potentially tragic mismanagement in the delivery room. Several reports have suggested that simulation-based training of delivery room teams in the management of obstetric emergencies, such as an eclamptic parturient or postpartum hemorrhage, may improve clinical performance and reduce the incidence of medical negligence.15–18
We initiated an experimental project that applies simulation technology to hands-on training of delivery room teams in managing extreme obstetric situations. A simulation-based course is supposed to reflect reality. Our rationale was that inaccurate techniques and management errors spotted during a full-scale simulation would be the same as those that occur repeatedly in real life. Our intent was that these errors would then provide the material for a simulation-based interventional program aimed at improving the ability of the teams to perform correctly in extreme situations such as those that might occur in the clinical setting.
MATERIALS AND METHODS
The project took place in the Israeli Center for Medical Simulation, which is equipped with computerized low-tech simulators and high-tech mannequins. Our first task was to choose extreme obstetric emergencies for simulating. We asked six senior perinatologists nationwide to identify those obstetric emergency scenarios that they regarded as essential for young residents. The scenarios chosen by most of them were these four: 1) preeclamptic patient with an eclamptic seizure, 2) an intractable postpartum hemorrhage, 3) shoulder dystocia, and 4) breech extraction.
Each team consisted of at least one resident in obstetrics and gynecology and two midwives. The tutors' panel consisted of six senior perinatologists and four experienced midwives who had earlier attended guidance sessions for trainers.
The conditions of eclamptic seizure and postpartum hemorrhage were created for full-scale, high-tech mannequins (Meti, METI Inc, Sarasota, FL; SimMan, Laerdal Medical Ltd, Orpington, Kent, UK). Each basic simulator required adaptation for obstetric requirements, such as a remote control seizure apparatus attached to the bed of the mannequin or a bleeding machine that could be attached to almost every organ, including the vagina (Fig. 1). We had to anticipate the actions that would most likely be taken by the trainees and then plan appropriate responses for the mannequin. Consequently, algorithms were created for the two scenarios, and they were fed into the computer attached to the mannequins in such a manner that the simulator acted independently in accordance with the treatment (or lack of it) administrated by the teams.
For the shoulder dystocia scenario, we used Noelle (Gaumard, Miami, FL), an obstetric and neonatal simulator package designed to demonstrate routine births, as well as known and unexpected perinatal complications. We mechanically delayed the birth of the shoulders after delivery of the presenting vertex and asked the trainees to conduct a full-scale shoulder dystocia drill from that point. After conducting a full-scale shoulder dystocia drill, trainees were asked to document the event.
Breech extraction was carried out on a low-tech female pelvis model into which a simple fetal mannequin was introduced in frank and complete breech presentations. Trainees were required to perform full breech extraction and assisted breech delivery under the supervision and with intervention, as needed, of experienced obstetricians and midwives. All research and educational activities at Israeli Center for Medical Simulation are conducted only after all participants provided their informed consent stating their willingness to take part in these activities.
Before each session the trainees were requested to fill out a questionnaire that included inquiries about general data about the trainee (age, gender, institutional affiliation, years of experience), level of experience in managing obstetric emergencies (as a case manager or as an active or passive participant), level of bedside teaching or guidance that the trainee had been exposed to in obstetric emergencies, and a self-estimation of the trainee's own ability to conduct such a case.
All four stations were videotaped from several angles by cameras distributed around the virtual delivery rooms. At the conclusion of each station, the teams viewed the video of their actions along with a senior obstetrician and an experienced midwife who assisted them in analyzing their mistakes and drawing conclusions in preparation for the next session.
Checklists containing a comprehensive list of actions required of the teams during each station were handed out to the tutors who observed the “event.” Tutors were asked to mark whether or not each action had been done appropriately according to predefined criteria. Each trainee was graded on a scale from 0 to 100 by a scoring system based on the filled out checklists. Feedback questionnaires were handed out to both the trainers and trainees before and after each session to determine the usefulness of and satisfaction from our simulation-based course. Detection of common and recurring mistakes was achieved by reviewing many hours of videotapes and summing up the data in the checklists.
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. All residents were in the first 3 years of a 6-year program: 14 (23%) in their first year (after 6 months of training at labor and delivery), 34 (57%) in their second year, and the remaining 12 (20%) in their third year of residency. The midwives had a mean delivery room experience of 2.5 years (range 1–8 years). The demographic characteristics of the trainees are shown in Table 1.
Questionnaire responses from the 148 trainees before participating in the course had showed that 68% were not trained to take independent action in any of the four selected obstetric emergencies, although 82% regarded their theoretical knowledge as satisfactory, and 62% believed that they would act competently and appropriately when required to do so. Most of them (64%) had never been required to take charge of such a scenario in real life.
The most common management errors and their frequency are detailed in Table 2. In the course of the eclamptic seizure scenario, most teams ventilated the patient either inefficiently or not at all and failed to detect magnesium sulfate intoxication. During the postpartum hemorrhage scenario, the vast majority of trainees underestimated the actual blood loss (of 3.5 L), and there was widespread unfamiliarity with the administration of prostaglandins to achieve hemostasis through myometrial stimulation and unacceptable delay in the decision to transport to the operating room (well after the mannequin had sunken into deep hypovolemic shock consequent to intractable bleeding). Most teams failed to properly document shoulder dystocia. Unexpectedly, one third of the teams did not perform an episiotomy throughout the shoulder dystocia drill, and more than half did so very late into the station. There were major difficulties in fixation of the limbs to prevent fractures during assisted breech delivery, and many trainees were not familiar with Mauriceau and Bracht maneuvers for extraction of the after-coming head.
Excluding few exceptions, the vast majority of teams (76%) scored in the range of 65–80 (mean±standard error 72.3±4.1) for all four scenarios. Lowest scores were for the postpartum hemorrhage and eclamptic seizure stations (mean 69.4 and 70, respectively), and the highest scores were for the shoulder dystocia drill and breech extraction model (74.1 and 76.6, respectively). The two on-going scenarios (postpartum hemorrhage and eclampsia) have similar elements, such as the organization, communication, and mission assignment phase, conducting basic life support, control of bleeding, and administration of blood products. Interestingly, teams did better on the second station than on the first (mean 67.5 for the first scenario and 72.8 for the second, P=.03, by Wilcoxon signed rank test), regardless of whether it was postpartum hemorrhage or eclampsia. No differences were detected in scoring between first-, second-, and third-year residents using nonparametric analysis of variance statistical test (Kruskal-Wallis test). Grades were markedly higher (mean 80.5±3.5, P=.023, Mann-Whitney test) on three occasions when experienced midwives (more than 6 years of training in the delivery room) participated. The interobserver variability between grading tutors was less than 10%.
A simulation based interventional program was tailored for each team after the feedback session. For example: trainees that had difficulties with fixation of the limbs in the course of breech delivery were instructed hands-on by experienced obstetrician using the simulators and picked up their skills by repeated practice.
Eighteen trainees, all of them residents, were invited to receive a repeat simulation-based training day at least 6 months after their first simulation-based training. With the intention of avoiding testing technical learning as opposed to incorporation and implementation (which were our goals), the scenarios were altered slightly. The scores of the trainees were significantly higher in the repeat sessions than in the primary hands-on course (Table 3). The main points of improvements were team organization and mission assignment, setting a case manager, knowledge of doses and mode of administration of commonly used drugs, and early transfer to the operating room in the postpartum hemorrhage scenario.
Postsession feedback from trainees indicated great interest (92%) in hands-on practice and confirmed the considerable discrepancy between theoretical knowledge and practical skills. Worthy of note is the fact that most (84%) trainees who had originally expressed being confident of their ability to perform appropriately in extreme obstetric situations retracted their original statements in the concluding feedback questionnaire.
Contemporary medical education applies virtual reality and simulation technology for training health care providers to a wide spectrum of skills and expertise, such as minimally invasive procedures (uteroscopy, endoscopy),16,17 endonasal surgery,18 laparoscopy,19,20 and trauma.21 Obstetric medical education lags behind, with only a few simulation-based courses for hands-on training of obstetricians worldwide.22,23 A group from the United Kingdom developed a simulation-based course for managing obstetric emergencies (Managing Obstetrical Emergencies and Trauma, MOET). The reliability of the model-based scenarios was demonstrated by a highly significant improvement in obstetric emergency management in developing countries (Armenia, Bangladesh).16,24–27
We developed a simulation-based course to provide hands-on practice for obstetric teams in dealing with emergency scenarios and were able to spot several recurring pitfalls of management for each scenario. The aim of the current project was to map common and recurrent mistakes to enable us, in the near future, to create a simulation-based interventional course specifically addressing the errors that had been detected. The hands-on training course enabled us to detect some of the most common mistakes made by obstetric teams under extreme pressure in life-threatening scenarios. For example, we found out that most residents are unfamiliar with prostaglandins administration in the treatment uterine atony. A simple interventional course aimed at guiding the trainees to administer the medication in an appropriate and timely fashion might have a tremendous impact on their ability to conduct a case of refractory uterine atony in the future. The late transfer to the operating room and delayed administration of blood products caused us to inquire about the decision-making process of the case managers. Apparently, the delayed actions stemmed from underestimation of blood loss. Almost without exception, all of the trainees inaccurately estimated blood loss by a mean factor of 50%. We are currently evaluating several ideas aimed at improving the precision of blood loss estimation by using simulation techniques.
It is impractical to assess the contribution of such training in “real life” because the low incidence of situations such as eclampsia. We managed to demonstrate an improvement in the performance of trainees participating in a previous simulation-based course. The higher grades in the repeated courses may be partially attributed to technical learning rather than assimilation. Trainees tend to memorize the sequence of events during a scenario and act accordingly in the repeated course. We aimed at incorporation and implementation of the correct management of obstetric emergencies; hence the repeated scenarios were altered to a certain extent while retaining the same objectives. This finding suggests that, indeed, simulation-based training in obstetric emergencies should play an important role in training and continuous medical education of labor and delivery teams and might improve outcome. Although the facilities and equipment required for conducting simulated scenarios require considerable financial outlay, benefits of such training might also be noticed and financially supported by professional authorities and malpractice insurance companies
1. Al-Assaf AF, Bumpus LJ, Carter D, Dixon SB. Preventing errors in healthcare: a call for action. Hosp Top 2003;81:5–12.
2. Kizer KW. Patient safety: a call to action: a consensus statement from the National Quality Forum. MedGenMed 2001;3:10.
3. Classen DC, Kilbridge PM. The roles and responsibility of physicians to improve patient safety within health care delivery systems. Acad Med 2002;77:963–72.
4. Flanagan B, Nestel D, Joseph M. Making patient safety the focus: crisis resource management in the undergraduate curriculum. Med Educ 2004;38:56–66.
5. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med 2003;78:783–8.
6. Shimada Y, Nishiwaki K, Cooper JB. Use of medical simulators subject of international study. J Clin Monit Comput 1998;14:499–503.
7. Issenberg SB, McGaghie WC, Hart IR, Mayer JW, Felner JM, Petrusa ER, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999;282:861–6.
8. Goodman W. The world of civil simulators. Flight International Magazine 1978;18:435.
9. Rolfe JM, Staples KJ. Flight simulation. Cambridge (UK): Cambridge University Press; 1986;232–49.
11. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;63:763–70.
12. Schwid HA. A flight simulator for general anesthesia training. Comput Biomed Res 1987;20:64–75.
13. Schwid HA, Rooke GA, Michalowski P, Ross BK. Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teach Learn Med 2001;13:92–6.
14. Chopra V, Gesink BJ, de Jong J, Bovill JG, Spierdijk J, Brand R. Does training on an anaesthesia simulator lead to improvement in performance? Br J Anaesth 1994;73:293–7.
15. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol 2003;102:388–92.
16. Letterie GS. How virtual reality may enhance training in obstetrics and gynecology. Am J Obstet Gynecol 2002;187:S37–40.
17. Pittini R, Oepkes D, Macrury K, Reznick R, Beyene J, Windrim R. Teaching invasive perinatal procedures: assessment of a high fidelity simulator-based curriculum. Ultrasound Obstet Gynecol 2002;19:478–83.
18. Lentz GM, Mandel LS, Lee D, Gardella C, Melville J, Goff BA. Testing surgical skills of obstetric and gynecologic residents in a bench laboratory setting: validity and reliability. Am J Obstet Gynecol 2001;184:1462–8; discussion 1468–70.
19. Watterson JD, Beiko DT, Kuan JK, Denstedt JD. Randomized prospective blinded study validating acquisition of ureteroscopy skills using computer based virtual reality endourological simulator. J Urol 2002;168:1928–32.
20. Neumann M, Hahn C, Horbach T, Schneider I, Meining A, Heldwein W, et al. Score card endoscopy: a multicenter study to evaluate learning curves in 1-week courses using the Erlangen Endo-Trainer. Endoscopy 2003;35:515–20.
21. Caversaccio M, Eichenberger A, Hausler R. Virtual simulator as a training tool for endonasal surgery. Am J Rhinol 2003;17:283–90.
22. Sung WH, Fung CP, Chen AC, Yuan CC, Ng HT, Doong JL. The assessment of stability and reliability of a virtual reality-based laparoscopic gynecology simulation system. Eur J Gynaecol Oncol 2003;24:143–6.
23. Nakajima K, Wasa M, Takiguchi S, Taniguchi E, Soh H, Ohashi S, et al. A modular laparoscopic training program for pediatric surgeons. JSLS 2003;7:33–7.
24. Lee SK, Pardo M, Gaba D, Sowb Y, Dicker R, Straus EM, et al. Trauma assessment training with a patient simulator: a prospective, randomized study. J Trauma 2003;55:651–7.
25. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol 2003;102:388–92.
26. Johanson RB, Menon V, Burns E, Kargramanya E, Osipov V, Israelyan M, et al. Managing Obstetric Emergencies and Trauma (MOET) structured skills training in Armenia, utilising models and reality based scenarios. BMC Med Educ 2002;2:5.
27. Johanson R, Akhtar S, Edwards C, Dewan F, Haque Y, Jones P. MOET: Bangladesh–an initial experience. J Obstet Gynaecol Res 2002;28:217–23.