EVEN HEALTHY, low-risk patients can have obstetric emergencies such as postpartum hemorrhage (PPH). However, because obstetric emergencies are rare and time-critical, healthcare team members may have difficulty responding with efficiency and confidence. This article describes how one organization used simulation to practice using teamwork and communication to respond effectively to a patient experiencing a PPH.
Understanding the issues
PPH is defined as blood loss of 1,000 mL or more within 24 hours after birth, and up to 12 weeks postpartum.1 This life-threatening emergency is a leading cause of maternal deaths. Because blood loss from a PPH is difficult to accurately assess, it's often underestimated. Treatment is based on clinical signs and symptoms and mode of delivery, with the main goal being to stop the bleeding.2
PPH is diagnosed with blood loss greater than or equal to 1,000 mL along with signs and symptoms of hypovolemia that cause hemodynamic instability within 24 hours after birth.3,4 Because early recognition of PPH is imperative to improving patient outcomes, all maternal–child clinicians should know how to recognize and manage PPH. Simulation training allows members of the healthcare team to practice low-volume, high-risk patient situations in a safe environment.
One hospital's project
Healthcare team members at a 152-bed children's and women's hospital who would likely respond to an obstetric emergency participated in PPH simulation training on the labor and delivery (L&D) unit. A high-fidelity maternal simulator was used for the scenario, which was followed by a bedside debriefing. The high-fidelity simulator integrates maternal–fetal physiology that is used for training for deliveries and other scenarios, both common and rare.4
The hospital's L&D unit has 15 private birthing suites, 4 recovery beds, and 8 screening rooms, which all promote family-centered care. The unit delivers more than 2,800 babies each year and has the only high-risk obstetrics unit in the area.
The institution-wide simulation program is interprofessional, serving all academic and clinical departments. The program uses simulation technology and standardized patient methodology to deliver high-quality, realistic, simulated clinical learning experiences. Its vision is to better prepare healthcare professionals for both discipline-specific and interprofessional practice. Because the program's infrastructure is purposefully and uniquely designed to serve the entire institution, collaborative efforts between academic departments and the academic health center are feasible and highly encouraged.
Identifying the need
The goals of this project were twofold: to assist the hospital in achieving The Joint Commission Perinatal Care Certification, and to provide training for new staff in the L&D unit. To grant this distinction, The Joint Commission requires an organization to demonstrate coordinated patient-centered care, identify high-risk pregnancies or births, and provide appropriate management and treatment. Interdisciplinary simulation training provides the staff with the tools needed to meet these requirements.5
In September 2015, the hospital quality management director contacted the simulation program to request assistance in providing the interdisciplinary simulation training. Before beginning the L&D simulation training, the simulation faculty and performance improvement team met to discuss scheduling, logistics, and learning objectives.
Team members included two simulation faculty (doctorally prepared RNs), the quality management director, an obstetrician–gynecologist, a hospital nurse educator, an L&D unit-based nurse educator, and a representative from the blood bank. PPH was the first disorder selected for interprofessional simulation training because of the recent development of a hospital maternal hemorrhage protocol and because maternal morbidity and mortality from PPH are high. Since 2014, there have been 65 reports of maternal death; most were due to hemorrhage.6 According to the American College of Obstetrics and Gynecology, maternal morbidity is an unintended outcome in the process of labor and delivery that leads to long- or short-term consequences for the mother.7
Staff preparedness in managing PPH was a concern voiced by the obstetric attending physician who's a member of the hospital performance improvement team. Because of a recent increase in newly hired RNs on the L&D unit, many staff members were inexperienced and unfamiliar with identifying and caring for a patient with a PPH. The performance improvement team recommended simulation training to help identify any gaps in staff education and skills, and to allow seasoned staff, nurses, and blood bank personnel to practice PPH management with the newly developed maternal hemorrhage protocol.
In situ and interprofessional approach
According to The Joint Commission, communication and teamwork failures are a major cause of adverse obstetric outcomes.8 Simulation training for healthcare providers improves communication and teamwork skills.9
Unlike simulation training conducted in a simulation lab, in situ simulation is physically integrated into the clinical environment, providing a way to accurately enhance reliability and safety of clinical processes and systems.10In situ simulation training was chosen because the traditional didactic method wouldn't provide the healthcare team with the hands-on clinical experiences needed to improve communication and teamwork.
In situ simulations are convenient for the team and maximize learning because the team is practicing in a familiar environment. This approach also provides a means to evaluate and analyze systems issues that affect patient care.11 Simulation training drills in the simulation lab wouldn't be as effective due to logistical challenges, especially for evening shift simulations.
Management for patients with PPH requires an interprofessional approach, and collaborative training is ideal for this. Interprofessional training and education occurs when members of two or more professions learn with, from, and about each other to improve collaboration and build a better patient-centered system.12
Several healthcare disciplines were represented in the obstetric simulation training. The healthcare team members (N = 48) included resident physicians, nurses, blood bank staff, anesthesia providers, cardiorespiratory therapy, pharmacy, admitting staff, and unit secretaries. Medical, nursing, and physician assistant students also participated when they were available. An average of seven or eight healthcare team members participated in a simulation training session at any given time, and all staff were encouraged to participate.
Although pharmacy staff doesn't directly participate in the simulation scenario, they're notified that simulation training is occurring in case they need to prepare simulated medications. The admitting staff doesn't attend because their role in the simulation was to ensure the simulated patient information was entered into the hospital computer system.
All healthcare team members were expected to learn how to manage the obstetric emergency while also learning about one another's role. Montgomery and colleagues reported that clinical care is most effectively delivered in teams.13 The National Academy of Medicine (formerly the Institute of Medicine) recommends the allocation of resources for interprofessional education and collaboration to include teamwork and performance in practice.14
PPH education and simulation
One month before the simulation training began, the unit educator launched PPH and simulation preparedness information to the staff via the hospital's online education system. (See Presimulation education with PPH electronic slide program.) The purpose of the information was to prepare the healthcare team for the simulation training and convey simulation expectations. The simulation faculty and performance improvement team wanted to give healthcare team members enough time to review the information before participating in the simulation training, so the team agreed on a 1-month time frame for this education.
The simulation scenario was developed using a preconfigured PPH Simulated Clinical Experience. It was modified, with its developer's permission, by the simulation faculty. A high-fidelity maternal simulator was used for the simulation training. Other supplies or equipment needed for the training included, but wasn't limited to, a transport stretcher, fetal and maternal monitors, a uterine tamponade balloon system, a uterine curette, and other scenario-specific items such as simulated medications and blood products, and I.V. fluids.
Simulation training was conducted on the L&D unit, and training occurred on day and night shifts. The simulation manikin was transported to the L&D unit and set up in a room. The simulation faculty demonstrated the simulator's capabilities and let the healthcare team ask questions before beginning.
Next, the simulation faculty provided the healthcare team with background information, such as patient history, and clinical status, including vital signs. The healthcare team then proceeded to provide care by assessing the patient, establishing a peripheral venous access device, providing supplemental oxygen, gathering equipment including a PPH kit, preparing and administering medications, making phone calls to other departments, and documenting in the simulated patient's electronic health record.
At the conclusion of each simulation scenario, the simulation faculty and obstetric attending physician led an interprofessional group debriefing. Group members were encouraged to be honest and forthright in the debriefing. As a result, key areas for communication improvement were identified, such as terminology to use when contacting the blood bank and information the nurse needed to relay to the resident physician when he or she arrived at the patient's bedside. Also identified were logistical areas for improvement related to supplies and equipment, scheduling, and personnel. Skills demonstrations were conducted when needed; for example, use of the uterine tamponade balloon.
Participant impressions survey
The healthcare team completed a Participant Impressions Survey (PIS), which was used to document the healthcare team members' impressions of the simulation training and their perceived preparedness for managing a PPH. The PIS was developed by one of the simulation faculty and completed by the healthcare team members after the simulation and group debriefing. The survey was composed of eight items and uses a 5-point Likert-scale format (1 means strongly disagree and 5 means strongly agree). The PIS evaluates how prepared the healthcare team members feel to work with other members of the healthcare team to manage a patient with PPH, their level of understanding of the hospital's PPH protocol, and the effectiveness of the interprofessional simulation. A section on the survey gives participants space for writing in what they learned from the simulation training as well as suggestions for future simulations.
The survey response rate was 100% (N = 48). PIS results reflected overall positive attitudes toward the interprofessional simulation. Based on analysis of the PIS, 92% to 94% of the healthcare team reported a 5 on the Likert scale in terms of being better prepared to manage a PPH, better prepared to work with other members of the healthcare team, and being more knowledgeable about the hospital's PPH protocol. In terms of what was learned from the simulation training, healthcare team members reported being more knowledgeable about use of the uterine tamponade balloon, medication dosages, location of the unit PPH kit, and location of the written hemorrhage protocol.
Based on participant feedback, the in situ simulation training was perceived as a beneficial and worthwhile project for preparing an interprofessional healthcare team to manage a patient with PPH. The healthcare team members reported that the interprofessional simulation training was more effective than lectures or online learning modules, and recommended several process improvements that are currently being implemented. For example, because the manufacturer of the uterine tamponade balloon recommends the use of 500 mL of I.V. fluid, the staff has now included a 500-mL bag of I.V. fluid (0.9% sodium chloride solution) in the PPH kit. This will ensure that I.V. fluid is readily available, and that the correct amount of fluid will be infused into the balloon.
Two limitations were identified during this project. First, because simulation training occurs in situ, cancellations due to high patient census or high acuity are possible. For example, the simulation training can't occur if the healthcare team is providing emergency care for a patient.
Second, not all staff may receive the simulation training due to scheduling. Healthcare team members who weren't scheduled when a simulation was provided missed the training.
Future endeavors and conclusion
Simulation faculty and the hospital performance improvement team are exploring ways to track quality improvement in PPH patient-care management moving forward. Because a PPH can occur in departments other than L&D, simulation training will continue and will be conducted on other units in the hospital, such as the high-risk obstetrics unit, mother/baby unit, and evaluation center. Other possible maternal and pediatric simulation scenarios will be identified through participant feedback and quality improvement needs.
Planned bimonthly in situ interprofessional simulation training will help the hospital acquire perinatal certification and improve patient care. Hands-on interprofessional training, such as this PPH exemplar, can provide a model for clinical training for other institutions striving for excellence in perinatal care. The goal is that patients will benefit from quality care given by informed and prepared healthcare professionals across disciplines.
Presimulation education with PPH electronic slide program
- PPH facts
- Causes of PPH
- Multidisciplinary approach for treatment and management of PPH
- Importance of blood product replacement
- The facility's massive transfusion protocol
- Obstetrics and gynecology alert
- Purpose and benefits of simulation
- Simulation philosophy
- Components of simulation
- - Teamwork
- - Patient safety
- - Quality
- - Respect for each other
- - Situational awareness.