Improving Neonatal Outcome Through Practical Shoulder Dystocia Training

Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios

AIM

Life threatening paediatric emergencies are relatively uncommon events. When they do occur staff caring for these children must have the ability to recognise the deterioration, evaluate and simultaneously treat these patients. The aim of this study was to identify suboptimal care during standardised simulated scenarios and to identify the potential causation factors.

METHODS

Participants were emergency department and operating theatre staff in Sydney, Australia. Incidents of suboptimal care were identified during scenarios and were analysed by thematic qualitative assessment methods. Potential causation factors were elicited both during and immediately after the scenarios and during facilitated debriefings. Causation factors were attributed to any of seven pre-defined categories.

RESULTS

Seventy-three simulations occurred over 9 month period in 2011. 270 doctors, 235 nurses and 11 students participated. 194 incidents of suboptimal care were observed and attributed to 325 causation factors. There were 76 knowledge deficits, 39 clinical skill deficits, 36 leadership problems, 84 communication failures, 20 poor resource utilisations, 23 preparation and planning failures and 47 incidents of a loss of situational awareness. Clinically important themes were: paediatric life support, drug choice and doses, advanced airway and ventilation, intravenous fluids and recognition of the deteriorating patient. Recurring incidents included the failure to recognise a cardiac arrest, inadequate fluid resuscitation and incorrect medication dose administration.

CONCLUSIONS

During standardised paediatric simulations multiple incidents of suboptimal care have been identified and multiple causation factors attributed to these. Educators should use this information to adapt current training programs to encompass these factors.

First-year residents outperform third-year residents after simulation-based education in critical care medicine

INTRODUCTION

Previous research shows that gaps exist in internal medicine residents' critical care knowledge and skills. The purpose of this study was to compare the bedside critical care competency of first-year residents who received a simulation-based educational intervention plus clinical training with third-year residents who received clinical training alone.

METHODS

During their first 3 months of residency, a group of first-year residents completed a simulation-based educational intervention. A group of traditionally trained third-year residents who did not receive simulation-based training served as a comparison group. Both groups were evaluated using a 20-item clinical skills assessment at the bedside of a patient receiving mechanical ventilation at the end of their medical intensive care unit rotation. Scores on the skills assessment were compared between groups.

RESULTS

Simulator-trained first-year residents (n = 40) scored significantly higher compared with traditionally trained third-year residents (n = 27) on the bedside assessment (91.3% [95% confidence interval, 88.2%-94.3%] vs. 80.9% [95% confidence interval, 76.8%-85.0%]; P < 0.001).

CONCLUSIONS

First-year residents who completed a simulation-based educational intervention demonstrated higher clinical competency compared with third-year residents who did not undergo simulation training. Critical care competency cannot be assumed after clinical intensive care unit rotations; simulation-based curricula can help ensure residents are proficient to care for critically ill patients.

Simulation Training in Health Care

In this chapter, we discuss the application of human factors and ergonomics to developing effective simulation training in health care. Simulation provides a safe, effective method for training and assessing human performance. In aviation, simulation-based training and assessment has been widely used, significantly improving safety. This progress would have been impossible without the involvement of human factors and ergonomics. Although aviation and health care have similarities, there also are differences that complicate the widespread implementation of simulation in health care.

Emergency obstetric simulation training: how do we know where we are going, if we don't know where we have been?

BACKGROUND

Obstetric emergencies contribute significantly to maternal morbidity and mortality. Current training in the management of obstetric emergencies in Australia and internationally focusses on utilising a multidisciplinary simulation-based model. Arguments for and against this type of training exist, using both economic and clinical reasoning.

AIMS

To identify the evidence base for the clinical impact of simulation training in obstetric emergencies and to address some of the concerns regarding appropriate delivery of obstetric emergency training in the Australian setting.

METHODS

A literature search was performed to identify research undertaken in the area of obstetric emergency training. The initial literature search using broad search terms identified 887 articles which were then reviewed and considered for inclusion if they provided original research with a specific emphasis on the impact of training on clinical outcomes.

RESULTS

Ninety-two articles were identified, comprising evidence in the following clinical situations: eclampsia, shoulder dystocia, postpartum haemorrhage, maternal collapse, cord prolapse and teamwork training. Evidence exists for a benefit in knowledge or skills gained from simulation training and for the benefit of training in small units without access to high-fidelity equipment or facilities.

CONCLUSIONS

Evidence exists for a positive impact of training in obstetric emergencies, although the majority of the available evidence applies to evaluation at the level of participants' confidence, knowledge or skills rather than at the level of impact on clinical outcomes. The model of simulation-based training is an appropriate one for the Australian setting and should be further utilised in rural and remote settings.

Retention of critical care skills after simulation-based mastery learning

BACKGROUND

Whether cognitive and patient care skills attained during simulation-based mastery learning (SBML) are retained is largely unknown.

OBJECTIVE

We studied retention of intensive care unit (ICU) clinical skills after an SBML boot camp experience.

METHODS

Forty-seven postgraduate year (PGY)-1 residents completed SBML intervention designed to increase procedural, communication, and patient care skills. The intervention included ICU skills such as ventilator and hemodynamic parameter management. Residents were required to meet or exceed a minimum passing score (MPS) on a clinical skills examination before starting actual patient care. Skill retention was assessed in 42 residents who rotated in the medical ICU. Residents received a standardized 15-minute booster teaching session reviewing key concepts during the first week of the rotation. During the fourth week of their rotation, PGY-1 residents completed a clinical skills examination at the bedside of an actual ICU patient. Group mean examination scores and the proportion of subjects who met or exceeded the MPS at each testing occasion were compared.

RESULTS

Residents scored a mean 90% (SD  =  6.5%) on the simulated skills examination immediately after training. Residents retained skills obtained through SBML as the mean score at bedside follow-up testing was 89% (SD  =  8.9%, P  =  .36). Thirty-seven of 42 (88%) PGY-1 residents met or exceeded the MPS at follow-up.

CONCLUSION

SBML leads to substantial retention of critical care knowledge, and patient care skills PGY-1 boot camp is a highly efficient and effective model that can be administered at the beginning of the academic year.

Implementation of laparoscopic virtual-reality simulation training in gynaecology: a mixed-methods design

OBJECTIVES

Virtual-reality (VR) training has been demonstrated to improve laparoscopic surgical skills in the operating theatre. The incorporation of laparoscopic VR simulation into surgical training in gynaecology remains a significant educational challenge. We undertook a pilot study to assess the feasibility of the implementation of a laparoscopic VR simulation programme into a single unit.

STUDY DESIGN

An observational study with qualitative analysis of semi-structured group interviews. Trainees in gynaecology (n=9) were scheduled to undertake a pre-validated structured training programme on a laparoscopic VR simulator (LapSim(®)) over six months. The main outcome measure was the trainees' progress through the training modules in six months. Trainees' perceptions of the feasibility and barriers to the implementation of laparoscopic VR training were assessed in focus groups after training.

RESULTS

Sixty-six percent of participants completed six of ten modules. Overall, feedback from the focus groups was positive; trainees felt training improved their dexterity, hand-eye co-ordination and confidence in theatre. Negative aspects included lack of haptic feedback, and facility for laparoscopic port placement training. Time restriction emerged as the main barrier to training.

CONCLUSIONS

Despite positive perceptions of training, no trainee completed more than two-thirds of the modules of a self-directed laparoscopic VR training programme. Suggested improvements to the integration of future laparoscopic VR training include an additional theoretical component with a fuller understanding of benefits of VR training, and scheduled supervision. Ultimately, the success of a laparoscopic VR simulation training programme might only be improved if it is a mandatory component of the curriculum, together with dedicated time for training. Future multi-centred implementation studies of validated laparoscopic VR curricula are required.

Patient outcomes in simulation-based medical education: a systematic review

OBJECTIVES

Evaluating the patient impact of health professions education is a societal priority with many challenges. Researchers would benefit from a summary of topics studied and potential methodological problems. We sought to summarize key information on patient outcomes identified in a comprehensive systematic review of simulation-based instruction.

DATA SOURCES

Systematic search of MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus, key journals, and bibliographies of previous reviews through May 2011.

STUDY ELIGIBILITY

Original research in any language measuring the direct effects on patients of simulation-based instruction for health professionals, in comparison with no intervention or other instruction.

APPRAISAL AND SYNTHESIS

Two reviewers independently abstracted information on learners, topics, study quality including unit of analysis, and validity evidence. We pooled outcomes using random effects.

RESULTS

From 10,903 articles screened, we identified 50 studies reporting patient outcomes for at least 3,221 trainees and 16,742 patients. Clinical topics included airway management (14 studies), gastrointestinal endoscopy (12), and central venous catheter insertion (8). There were 31 studies involving postgraduate physicians and seven studies each involving practicing physicians, nurses, and emergency medicine technicians. Fourteen studies (28 %) used an appropriate unit of analysis. Measurement validity was supported in seven studies reporting content evidence, three reporting internal structure, and three reporting relations with other variables. The pooled Hedges' g effect size for 33 comparisons with no intervention was 0.47 (95 % confidence interval [CI], 0.31-0.63); and for nine comparisons with non-simulation instruction, it was 0.36 (95 % CI, -0.06 to 0.78).

LIMITATIONS

Focused field in education; high inconsistency (I(2) > 50 % in most analyses).

CONCLUSIONS

Simulation-based education was associated with small-moderate patient benefits in comparison with no intervention and non-simulation instruction, although the latter did not reach statistical significance. Unit of analysis errors were common, and validity evidence was infrequently reported.

Evaluating educational interventions in emergency medicine

This article presents the proceedings of the 2012 Academic Emergency Medicine consensus conference breakout group charged with identifying areas necessary for future research regarding effectiveness of educational interventions for teaching emergency medicine (EM) knowledge, skills, and attitudes outside of the clinical setting. The objective was to summarize both medical and nonmedical education literature and report the consensus formation methods and results. The authors present final statements to guide future research aimed at evaluating the best methods for understanding and developing successful EM curricula using all types of educational interventions.

Obstetric emergency simulation

Simulation for obstetric emergencies has progressed from being a good idea in theory to the level of an evidence-based intervention that can improve outcomes. Though not a stand-alone solution, the inclusion of simulation for training individuals and teams to react and perform correctly when obstetric emergencies occur is a critical part of a comprehensive strategy to improve outcomes for both the mother and baby. In this article, we will briefly review both the recent history of simulation for obstetric emergencies and then examine the most current evidence for specific emergencies.

The use of simulation in maternal-fetal medicine procedure training

Many fields of medicine now routinely employ simulation while educating all levels of medical trainees. Unfortunately, OB-GYN has been slow to incorporate these beneficial adjuncts to traditional medical education, but thankfully the use of simulation is now increasing. Maternal-Fetal medicine procedures such as amniocentesis, in-utero stent placement, chorionic villus sampling, percutaneous umbilical blood sampling, and cervical cerclage placements are an area where simulation has great potential benefit. Here we describe the currently available simulation models for these procedures and outline specific training curricula designed to aid trainees in obtaining procedural competency in each. Although initial experiences with these training models and the curricula centered around them have been positive, in many cases their use remains limited. Our hope is that this manuscript will encourage others to incorporate simulation into their training programs as we believe it will enhance medical training and improve patient safety.

Advances in recognition, resuscitation, and stabilization of the critically ill child

Advances in early recognition, effective response, and high-quality resuscitation before, during, and after cardiac arrest have resulted in improved survival for infants and children over the past 10 years. This review addresses several key factors that can make a difference in survival outcomes, including the etiology of pediatric cardiac arrests in and out of hospital, mechanisms and techniques of circulation of blood flow during cardiopulmonary resuscitation (CPR), quality of CPR, meticulous postresuscitative care, and effective training. Monitoring and quality improvement of each element in the system of resuscitation care are increasingly recognized as key factors in saving lives.

Simulation: improving patient outcomes

Effective training has been shown to improve perinatal care and outcome, decrease litigation claims and reduce midwifery sick leave. To be effective, training should be incentivised, in a realistic context, and delivered to inter-professional teams similar to those delivering actual care. Teamwork training is a useful addition, but it should be based on the characteristics of effective teamwork as derived from the study of frontline teams. Implementation of simulation and teamwork training is challenging, with constraints on staff time, facilities and finances. Local adoption and adaptation of effective programmes can help keep costs down, and make them locally relevant whilst maintaining effectiveness. Training programmes need to evolve continually in line with new evidence. To do this, it is vital to monitor outcomes and robustly evaluate programmes for their impact on patient care and outcome, not just on participants.

Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies

Poor teamwork results in preventable morbidity and mortality for mothers and babies. Suboptimal communication and lack of leadership cost not only lives but also money that is diverted from clinical care to insurance and litigation. Avoidable harm is usually not the result of staff failing their duty of care, it is the result of poor training failing hard-worked staff. A few simple teamwork and leadership behaviours can make a huge difference to outcome and experience for women and their companions, yet they are often missing from maternity care. Recent research has identified the problems and solutions, including the best way to train maternity teams to make a palpable difference. We describe simple yet evidence-based methods to improve teams and leaders.

Teaching medical students a clinical approach to altered mental status: simulation enhances traditional curriculum

INTRODUCTION

Simulation-based medical education (SBME) is increasingly being utilized for teaching clinical skills in undergraduate medical education. Studies have evaluated the impact of adding SBME to third- and fourth-year curriculum; however, very little research has assessed its efficacy for teaching clinical skills in pre-clerkship coursework. To measure the impact of a simulation exercise during a pre-clinical curriculum, a simulation session was added to a pre-clerkship course at our medical school where the clinical approach to altered mental status (AMS) is traditionally taught using a lecture and an interactive case-based session in a small group format. The objective was to measure simulation's impact on students' knowledge acquisition, comfort, and perceived competence with regards to the AMS patient.

METHODS

AMS simulation exercises were added to the lecture and small group case sessions in June 2010 and 2011. Simulation sessions consisted of two clinical cases using a high-fidelity full-body simulator followed by a faculty debriefing after each case. Student participation in a simulation session was voluntary. Students who did and did not participate in a simulation session completed a post-test to assess knowledge and a survey to understand comfort and perceived competence in their approach to AMS.

RESULTS

A total of 154 students completed the post-test and survey and 65 (42%) attended a simulation session. Post-test scores were higher in students who attended a simulation session compared to those who did not (p<0.001). Students who participated in a simulation session were more comfortable in their overall approach to treating AMS patients (p=0.05). They were also more likely to state that they could articulate a differential diagnosis (p=0.03), know what initial diagnostic tests are needed (p=0.01), and understand what interventions are useful in the first few minutes (p=0.003). Students who participated in a simulation session were more likely to find the overall AMS curriculum useful (p<0.001).

CONCLUSION

Students who participated in a simulation exercise performed better on a knowledge-based test and reported increased comfort and perceived competence in their clinical approach to AMS. SBME shows significant promise for teaching clinical skills to medical students during pre-clinical curriculum.

Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance

OBJECTIVE

We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean.

STUDY DESIGN

Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children's Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision.

RESULT

The median (interquartile range) from time zero until incision was 9 min 27 s (8:55 to 10:27 min:s).

CONCLUSION

In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery.

Interns' success with clinical procedures in infants after simulation training

BACKGROUND AND OBJECTIVE

Simulation-based medical education (SBME) is used to teach residents. However, few studies have evaluated its clinical impact. The goal of this study was to evaluate the impact of an SBME session on pediatric interns' clinical procedural success.

METHODS

This randomized trial was conducted at 10 academic medical centers. Interns were surveyed on infant lumbar puncture (ILP) and child intravenous line placement (CIV) knowledge and watched audiovisual expert modeling of both procedures. Participants were randomized to SBME mastery learning for ILP or CIV and for 6 succeeding months reported clinical performance for both procedures. ILP success was defined as obtaining a sample on the first attempt with <1000 red blood cells per high-power field or fluid described as clear. CIV success was defined as placement of a functioning catheter on the first try. Each group served as the control group for the procedure for which they did not receive the intervention.

RESULTS

Two-hundred interns participated (104 in the ILP group and 96 in the CIV group). Together, they reported 409 procedures. ILP success rates were 34% (31 of 91) for interns who received ILP mastery learning and 34% (25 of 73) for controls (difference: 0.2% [95% confidence interval: -0.1 to 0.1]). The CIV success rate was 54% (62 of 115) for interns who received CIV mastery learning compared with 50% (58 of 115) for controls (difference: 3% [95% confidence interval: -10 to 17]).

CONCLUSIONS

Participation in a single SBME mastery learning session was insufficient to affect pediatric interns' subsequent procedural success.

Using simulation to teach nursing students and licensed clinicians obstetric emergencies

Improving patient safety in healthcare has reached critical mass both in the United States and worldwide. Effective communication between nurses and other members of the healthcare team is an essential component of patient safety. In obstetrics, poor communication and teamwork were causative factors in many of reviewed sentinel event cases. Simulation is a recommended teaching strategy used to improve communication and teamwork skills, and therefore patient safety, among interprofessional team members. This article offers a strategy in the form of a shoulder dystocia simulation that can be implemented in either academic or clinical settings. Simulations such as this one can be used to enhance teamwork and communication skills of healthcare professionals, both in educational institutions and in clinical practice settings, with a goal of improving patient safety.

Translational educational research: a necessity for effective health-care improvement

Medical education research contributes to translational science (TS) when its outcomes not only impact educational settings, but also downstream results, including better patient-care practices and improved patient outcomes. Simulation-based medical education (SBME) has demonstrated its role in achieving such distal results. Effective TS also encompasses implementation science, the science of health-care delivery. Educational, clinical, quality, and safety goals can only be achieved by thematic, sustained, and cumulative research programs, not isolated studies. Components of an SBME TS research program include motivated learners, curriculum grounded in evidence-based learning theory, educational resources, evaluation of downstream results, a productive research team, rigorous research methods, research resources, and health-care system acceptance and implementation. National research priorities are served from translational educational research. National funding priorities should endorse the contribution and value of translational education research.

Making July safer: simulation-based mastery learning during intern boot camp

PURPOSE

Patient care quality worsens during academic year turnover. Incoming interns' uneven clinical skills likely contribute to this phenomenon, known as the "July effect." The aim of this study was to evaluate the impact of a simulation-based mastery learning (SBML) boot camp on internal medicine interns' clinical skills.

METHOD

This was a cohort study of an SBML intervention at Northwestern University. In 2011, 47 interns completed boot camp; 109 interns (from 2009 and 2010) who did not participate in boot camp were historical controls. Boot-camp-trained interns participated in three days of small-group teaching sessions, deliberate practice, and individualized feedback. Primary outcome measures were performance of boot-camp-trained interns and historical controls on five parts of a clinical skills examination (CSE). Assessments included recognition of physical examination findings (cardiac auscultation), performance of procedures (paracentesis and lumbar puncture), management of critically ill patients (intensive care unit skills), and communication with patients (code status discussion). Boot camp participants were required to meet or exceed a minimum passing standard (MPS) before beginning their internship.

RESULTS

Boot-camp-trained interns all eventually met or exceeded the MPS and performed significantly better than historical control interns on all skills (P < .01), even after controlling for age, gender, and USMLE Step 1 and 2 scores (P < .001). The authors detected no relationship between CSE scores and age, gender, prior experience, self-confidence, or USMLE Step 1 and 2 scores.

CONCLUSIONS

An SBML boot camp allows for individualized training, assessment, and documentation of competence before interns begin providing medical care.

The role of high-fidelity simulation in training pediatric emergency medicine fellows in the United States and Canada

OBJECTIVES

The American Academy of Pediatrics Section on Emergency Medicine's Simulation Interest Group developed a survey targeting pediatric emergency medicine (PEM) fellowship program directors to assess the use of high-fidelity simulation (HFS) in PEM fellow training.

METHODS

Content experts in simulation and in PEM developed a 38-item Internet-based questionnaire that was distributed to PEM program directors via e-mail though www.surveymonkey.com.

RESULTS

Seventy-seven percent (51/66) of PEM program directors in the United States and Canada responded to the survey. Sixty-three percent of programs incorporate HFS in PEM fellowship training. For programs with HFS, the most frequent uses of HFS include (1) decision making for trauma resuscitations (97%, 31/32) and medical emergencies (91%, 29/32), and for the application of advanced life support (84%, 27/32); (2) technical skills: intubation (100%, 31/31), bag-mask ventilation (94%, 29/31), cardioversion/defibrillation (90%, 28/31), and difficult airway management (84%, 26/31). Of program directors without simulation, a majority valued simulation for PEM fellow training, and 59% (11/19) plan on expanding efforts. Perceived barriers to an active simulation program exist: lack of financial support (79%, 15/19), lack of simulator equipment (74%, 14/19), lack of a dedicated physical space (68%, 13/19), and insufficiently experienced simulation faculty (58% 11/19).

CONCLUSIONS

Sixty-three percent of PEM fellowship programs integrate HFS-based activities. The majority of PEM fellowship program directors value the role of HFS in augmenting clinical experience and documenting procedural skills. Regional simulation centers are one possible solution to offer HFS training to fellowships with limited financial support and/or lack of experienced simulation faculty.

Team Resource Management im OP und in der Endoskopie

<b><i>Hintergrund: </i></b>Klinischem Handeln ist implizit, dass die große Mehrzahl an risikoreichen und gleichzeitig prognoserelevanten Handlungen am Patienten nicht durch Einzelne erfolgt, sondern die Resultate einer Teamleistung (bisweilen ad hoc) sind. <b><i>Methode: </i></b>Publizierte Forschungsergebnisse zeigen nachvollziehbare Befunde, welche die Ursachen von Fehlermechanismen und -ketten darstellen und die Wirksamkeit von TRM(Team Resource Management)-Trainingsformaten belegen. <b><i>Ergebnisse: </i></b>Die Analyse der Literaturbefunde seit 2003 zeigt deutlich, dass die Ursache von prognose- oder zwischenfallrelevanten Fehlerketten in der klinischen Medizin zu mehr als 70% den Anwendern zuzuordnen ist. Die Implementierung und kontinuierliche Weiterentwicklung der Patientensicherheit im Bereich der Human Factors und die Anwendung der TRM-Leitsätze erfordert als Basis eine gute und breit akzeptierte Sicherheitskultur. <b><i>Schlussfolgerungen: </i></b>Initiativmaßnahmen wie regelmäßige realitätsnahe Simulationsteamtrainings, TRM-Formate und gut etablierte nichtpunitive Incident-Reporting-Systeme können hierbei effektiv zu einer stetigen und messbaren Verbesserung der Sicherheitskultur beitragen.

Review article: simulation: a means to address and improve patient safety

PURPOSE

The purpose of this article is to review the role of technical and nontechnical skills in routine and crisis situations. We discuss the role of different simulation modalities in addressing these skills and competencies to enhance patient safety.

PRINCIPAL FINDINGS

Human and system errors are a recognized cause of significant morbidity and mortality. Technical skills encompass the medical and procedural knowledge required for patient care, while nontechnical skills are behaviour-based and include task management, situation awareness, teamwork, decision-making, and leadership. Both sets of skills are required to improve patient safety. Healthcare simulation can provide an opportunity to practice technical and nontechnical skills in a patient-safe environment. More specifically, these skills are most required in dynamic and crisis situations, which may best be practiced in a simulated patient setting.

CONCLUSION

Healthcare simulation is a valuable tool to improve patient safety. Simulation-based education can focus on the necessary technical and nontechnical skills to enhance patient safety. Simulation-based research can serve as a means to identify gaps in current practice, test different solutions, and show improved practice patterns by studying performance in a setting that does not compromise patient safety.

The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives

Simulation-based educational processes are emerging as key tools for assessing and improving patient safety. Multidisciplinary or interprofessional simulation training can be used to optimize crew resource management and safe communication principles. There is good evidence that simulation training improves self-confidence, knowledge, and individual and team performance on manikins. Emerging evidence supports that procedural simulation, deliberate practice, and debriefing can also improve operational performance in clinical settings and can result in safer patient and population/system outcomes in selected settings. This article highlights emerging evidence that shows how simulation-based interventions and education contribute to safer, more efficient systems of care that save lives.

Teamwork for clinical emergencies: interprofessional focus group analysis and triangulation with simulation

Our purpose was to investigate health care professionals' beliefs about effective teamwork in medical emergencies based on their experiences. We used framework analysis of interprofessional focus groups in four secondary and tertiary maternity units. The participants were randomly selected senior and junior doctors, senior and junior midwives, and health care assistants, in five groups of 5 to 7 participants each. We found that optimal teamwork was perceived to be dependent on good leadership and availability of experienced staff. The participants described a good leader as one who verbally declares being the leader, communicates clear objectives, and allocates critical tasks, including communication with patients or their family, to suitable individual members. We triangulated the results with evidence from simulation to identify convergent findings and issues requiring further research. The findings will inform the development of teaching programs for medical teams who manage emergencies to improve patient safety and experience.

A Systematic Review of Simulators in Otolaryngology

Objective

To conduct a systematic review of published articles that describe simulators that could be used in otolaryngology for education, skill acquisition, and/or skill improvement.

Data Sources

Ovid and Embase databases searched July 14, 2011.

Review Methods

Three hundred fifty-three abstracts were independently reviewed by both authors, then 154 eligible articles were reviewed by both authors, and 95 articles were categorized by organ system (eg, otologic); type of simulator (eg, physical, virtual); whether the simulator was a prototype, could be purchased, or was constructed; validation; and level of learning assessment. Discrepancies were resolved by re-review and discussion.

Results

In addition to 11 overview articles, 28 articles described 16 otology simulators, most of which are virtual and prototypes. Ninteen articles described 10 sinus/rhinology simulators; most are virtual surgery simulators and prototypes. Eight articles described 8 oral cavity simulators, and 8 articles described neck simulators. Seventeen articles described 13 bronchoscopy simulators; several are full-body high-technology manikins adapted from other purposes. Five articles described eclectic simulators, including some for learning nontechnical and teamwork skills. Half of the simulators have been validated. Learning levels were often not assessed or assessment was limited to the learners’ perceptions.

Conclusion

A wide variety of simulators are available or under development. Lack of unified validation concepts and limited descriptions restricted our ability to assess model characteristics, availability, and validation. Simulators are emerging as powerful tools to facilitate learning; this review may provide a platform for discussion and refinement of the information reported and analyzed in evaluating simulators.

Outcomes associated with a structured prenatal counseling program for shoulder dystocia with brachial plexus injury

OBJECTIVE

We examined outcomes that were associated with a novel program to identify patients who are at high risk for shoulder dystocia with brachial plexus injury.

STUDY DESIGN

The program included a checklist of key risk factors and a multifactorial algorithm to estimate risk of shoulder dystocia with brachial plexus injury. We examined rates of cesarean delivery and shoulder dystocia in 8767 deliveries by clinicians who were enrolled in the program and in 11,958 patients of clinicians with no access to the program.

RESULTS

Key risk factors were identified in 1071 of 8767 mothers (12.2%), of whom 40 of 8767 women (0.46%) had results in the high-risk category. The rate of primary cesarean delivery rate was stable (21.2-20.8%; P = .57). Shoulder dystocia rates fell by 56.8% (1.74-0.75%; P = .002). The rates of shoulder dystocia and cesarean birth showed no changes in the group with no access to the program.

CONCLUSION

With the introduction of this program, overall shoulder dystocia rates fell by more than one-half with no increase in the primary cesarean delivery rate.

Abdominal Access for Shoulder Dystocia as a Last Resort - a Case Report

Shoulder dystocia is the term used to describe failure to progress in labour after the head has been delivered due to insufficient rotation of the shoulders. It is unpredictable and cannot be prevented by the midwife or the obstetrician. We report here on a severe case of shoulder dystocia, where delivery of the shoulder was finally achieved through direct pressure on the anterior shoulder after laparotomy and uterotomy with concurrent vaginal Woods screw manoeuvre and was followed by vaginal delivery. The patient presented risk factors like maternal obesity and administration of labour-inducing drugs. After different manoeuvres like McRoberts manoeuvre and several manoeuvres for internal rotation were carried out unsuccessfully, an emergency laparotomy was performed. The newborn was in need for reanimation and artifical ventilation postpartum but recovered fast during the following days. An Erb's palsy of the posterior arm improved during the hospital stay. The German Guideline of the DGGG 8 recommends a risk management plan and regular training to all birth attendants for obstetric clinics. Beside the vaginal manoeuvres one should have at least theoretical expertise in operative manoeuvres to be able to perform them in emergency cases.

The case for simulation as part of a comprehensive patient safety program

Simulation in obstetrics allows us to practice in a safe environment. Simulations can improve the performance of individuals and obstetric teams. The evidence is overwhelming that, with simulated practice, obstetricians improve their technical and communication skills. Evidence is emerging that simulation ultimately may improve clinical outcomes. It stands to reason that simulation in obstetrics should be incorporated into comprehensive patient safety programs.

Role of effective teamwork and communication in delivering safe, high-quality care

Healthcare is delivered in an extraordinary complex environment. Despite highly skilled, dedicated clinicians, there are currently unacceptably high levels of communication failures and adverse events. Effective teamwork, in conjunction with reliable processes of care, is essential for the consistent delivery of high-quality care. Practical concepts and tools are provided that address the team behaviors of structured communication, effective assertion/critical language, psychological safety, situational awareness, and effective leadership. Examples of the mounting clinical evidence of improved patient outcomes and reduced harm resulting from effective teamwork training are cited.

Can shoulder dystocia be reliably predicted?

AIMS

To evaluate factors reported to increase the risk of shoulder dystocia, and to evaluate their predictive value at a population level.

METHODS

The South Australian Pregnancy Outcome Unit's population database from 2005 to 2010 was accessed to determine the occurrence of shoulder dystocia in addition to reported risk factors, including age, parity, self-reported ethnicity, presence of diabetes and infant birth weight. Odds ratios (and 95% confidence interval) of shoulder dystocia was calculated for each risk factor, which were then incorporated into a logistic regression model. Test characteristics for each variable in predicting shoulder dystocia were calculated.

RESULTS

As a proportion of all births, the reported rate of shoulder dystocia increased significantly from 0.95% in 2005 to 1.38% in 2010 (P = 0.0002). Using a logistic regression model, induction of labour and infant birth weight greater than both 4000 and 4500 g were identified as significant independent predictors of shoulder dystocia. The value of risk factors alone and when incorporated into the logistic regression model was poorly predictive of the occurrence of shoulder dystocia.

CONCLUSIONS

While there are a number of factors associated with an increased risk of shoulder dystocia, none are of sufficient sensitivity or positive predictive value to allow their use clinically to reliably and accurately identify the occurrence of shoulder dystocia.