Improving Neonatal Outcome Through Practical Shoulder Dystocia Training

Complications of labor and delivery: shoulder dystocia

This article reviews one of the less common but most dreaded complications of labor and delivery, shoulder dystocia, an infrequent but potentially devastating event that results from impaction of the fetal shoulders in the maternal pelvis. Shoulder dystocia occurs most commonly in patients without identified risk factors, and can result in both maternal and fetal morbidity. Because the vast majority of cases of shoulder dystocia are unpredictable, obstetric care providers must be prepared to recognize dystocia and respond appropriately in every delivery. Detailed documentation is essential after any delivery complicated by shoulder dystocia.

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

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

Simulation for maintenance of certification in anesthesiology: the first two years

The ultimate goal of physician education is the application of knowledge and skills to patient care. The Maintenance of Certification (MOC) for Anesthesiologists program incorporates mannequin-based simulation to help realize this goal. Results from the first 2 years of experience suggest that 583 physician participants transferred knowledge and skills from their simulated experiences into real-world practice. Participants consistently found the experience educationally valuable and clinically relevant, and reported that it led to changes in practice. This first experience with mannequin-based simulation for MOC indicates that physicians accept this teaching modality, many with enthusiasm. Simulation education addresses many of the identified intentions of current continuing medical education (CME) and can help educators realize goals for educating physician-learners.

Judicious use of simulation technology in continuing medical education

Use of simulation-based training is fast becoming a vital source of experiential learning in medical education. Although simulation is a common tool for undergraduate and graduate medical education curricula, the utilization of simulation in continuing medical education (CME) is still an area of growth. As more CME programs turn to simulation to address their training needs, it is important to highlight concepts of simulation technology that can help to optimize learning outcomes. This article discusses the role of fidelity in medical simulation. It provides support from a cross section of simulation training domains for determining the appropriate levels of fidelity, and it offers guidelines for creating an optimal balance of skill practice and realism for efficient training outcomes. After defining fidelity, 3 dimensions of fidelity, drawn from the human factors literature, are discussed in terms of their relevance to medical simulation. From this, research-based guidelines are provided to inform CME providers regarding the use of simulation in CME training.

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture.

Medical simulation for professional development--science and practice

From the earliest days of medical practice, when surgeons used cadavers to explore the possibilities of surgical intervention, simulation has been employed to advance the practice of health care. In the last 10 years, technological advances have allowed for a wider availability and greater realism of simulation, and this has encouraged a great expansion in its use. Simulation aims to create a virtuous cycle of professional development to improve patient outcomes. Although it seems eminently logical to believe that simulation will result in better outcomes, there is a need to test these new training interventions rigorously to be sure of their worth and to understand any limitations. The purpose of this BJOG supplement is to examine in depth several paradigms of medical simulation within maternity care and gynaecology, in different settings, looking at what can be achieved and how. In this opening review, we look at the potential use of medical simulation in broad terms and describe the types of evidence that can be employed to support its use.

Airway challenges in critical care

Airway management in the intensive care unit is more problematic than during anaesthesia. In general, critically ill patients have less physiological reserve and complications are more common, both during the initial airway intervention (which includes risks associated with induction of anaesthesia), and later once the airway has been secured. Despite these known risks, those managing the airway of a critically ill patient, particularly out of hours, may be relatively inexperienced. Solutions to these challenging airway problems include: recognition of those patients with a potential airway problem; implementation of a plan to deal with their airway; immediate availability of a difficult airway trolley; use of capnography for every airway intervention and continuously in all ventilator-dependent patients; and appropriate training of all intensive care unit staff including use of simulation.

Literature review: instructional design and pedagogy science in healthcare simulation

This article is a review of the literature focused on simulation as an educational intervention in healthcare. The authors examined the literature based on four key levels: (1) the validity and reliability of the simulator, (2) the validity and reliability of the performance evaluation tool, (3) the study design, and (4) the translational impact. The authors found that the majority of research literature in healthcare simulation does not address the validity and reliability of the simulator or the performance evaluation tool. However, there are well-designed research studies that address the translation into clinical settings and have positive patient safety outcomes.

Evaluating the impact of simulation on translational patient outcomes

INTRODUCTION

A long and rich research legacy shows that under the right conditions, simulation-based medical education (SBME) is a powerful intervention to increase medical learner competence. SBME translational science demonstrates that results achieved in the educational laboratory (T1) transfer to improved downstream patient care practices (T2) and improved patient and public health (T3).

METHOD

This is a qualitative synthesis of SBME translational science research (TSR) that employs a critical review approach to literature aggregation.

RESULTS

Evidence from SBME and health services research programs that are thematic, sustained, and cumulative shows that measured outcomes can be achieved at T1, T2, and T3 levels. There is also evidence that SBME TSR can yield a favorable return on financial investment and contributes to long-term retention of acquired clinical skills. The review identifies best practices in SBME TSR, presents challenges and critical gaps in the field, and sets forth a TSR agenda for SBME.

CONCLUSIONS

Rigorous SBME TSR can contribute to better patient care and improved patient safety. Consensus conference outcomes and recommendations should be presented and used judiciously.

Outcomes associated with introduction of a shoulder dystocia protocol

The objective of this study was to assess outcomes that are associated with the implementation of a shoulder dystocia protocol that is focused on team response. We identified women who had a shoulder dystocia during 3 time periods: 6 months before (period A), 6 months during (period B), and 6 months after (period C) the institution of a shoulder dystocia protocol. Documentation and health outcomes were compared among the time periods. During the study period, 254 women (77, 100, and 77 in periods A, B, and C, respectively) had a shoulder dystocia. There were no differences among study periods in patient characteristics. However, complete and consistent documentation increased (14% to 50% to 92%; P < .001), and brachial plexus palsy that was diagnosed at delivery (10.1% to 4.0% to 2.6%; P = .03) and at neonatal discharge (7.6% to 3.0% to 1.3%; P = .04) declined.

Unexpected collateral effects of simulation-based medical education

PURPOSE

Internal medicine residents who complete simulation-based education (SBE) in central venous catheter (CVC) insertion acquire improved skills that yield better patient care outcomes. The collateral effects of SBE on the skills of residents who have not yet experienced SBE are unknown.

METHOD

In this retrospective, observational study, the authors used a checklist to test the internal jugular and subclavian CVC insertion skills of 102 Northwestern University second- and third-year internal medicine residents before they received simulation training. The authors compared, across consecutive academic years (2007-2008, 2008-2009, 2009-2010), mean pretraining scores and the percent of trainees who met or surpassed a minimum passing score (MPS).

RESULTS

Mean internal jugular pretest scores improved from 46.7% (standard deviation = 20.8%) in 2007 to 55.7% (±22.5%) in 2008 and 70.8% (±22.4%) in 2009 (P < .001). Mean subclavian pretest scores changed from 48.3% (±25.5%) in 2007 to 45.6% (±31.0%) in 2008 and 63.6% (±27.3%) in 2009 (P = .04). The percentage of residents who met or surpassed the MPS before training for internal jugular insertion was 7% in 2007, 16% in 2008, and 38% in 2009 (P = .004); for subclavian insertion, the percentage was 11% in 2007, 19% in 2008, and 38% in 2009 (P = .028).

CONCLUSIONS

SBE for senior residents had an effect on junior trainees, as evidenced by pretraining CVC insertion skill improvement across three consecutive years. SBE for a targeted group of residents has implications for skill acquisition among other trainees.

PRONTO training for obstetric and neonatal emergencies in Mexico

OBJECTIVE

To evaluate the acceptability, feasibility, rating, and potential impact of PRONTO, a low-tech and high-fidelity simulation-based training for obstetric and neonatal emergencies and teamwork using the PartoPants low-cost birth simulator.

METHODS

A pilot project was conducted from September 21, 2009, to April 9, 2010, to train interprofessional teams from 5 community hospitals in the states of Mexico and Chiapas. Module I (teamwork, neonatal resuscitation, and obstetric hemorrhage) was followed 3 months later by module II (dystocia and pre-eclampsia/eclampsia) and an evaluation. Four elements were assessed: acceptability; feasibility and rating; institutional goal achievement; teamwork improvement; and knowledge and self-efficacy.

RESULTS

The program was rated highly both by trainees and by non-trainees who completed a survey and interview. Hospital goals identified by participants in the module I strategic-planning sessions were achieved for 65% of goals in 3 months. Teamwork, knowledge, and self-efficacy scores improved.

CONCLUSION

PRONTO brings simulation training to low-resource settings and can empower interprofessional teams to respond more effectively within their institutional limitations to emergencies involving women and newborns. Further study is warranted to evaluate the potential impact of the program on obstetric and neonatal outcome.

Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial

PURPOSE

The purpose of this study is to determine the effect of simulation-based education on the knowledge and skills of internal medicine residents in the medical intensive care unit (MICU).

METHODS AND MATERIALS

From January 2009 to January 2010, 60 first-year residents at a tertiary care teaching hospital were randomized by month of rotation to an intervention group (simulator-trained, n = 26) and a control group (traditionally trained, n = 34). Simulator-trained residents completed 4 hours of simulation-based education before their medical intensive care unit (MICU) rotation. Topics included circulatory shock, respiratory failure, and mechanical ventilation. After their rotation, residents completed a standardized bedside skills assessment using a 14-item checklist regarding respiratory mechanics, ventilator settings, and circulatory parameters. Performance of simulator-trained and traditionally trained residents was compared using a 2-tailed independent-samples t test.

RESULTS

Simulator-trained residents scored significantly higher on the bedside skills assessment compared with traditionally trained residents (82.5% ± 10.6% vs 74.8% ± 14.1%, P = .027). Simulator-trained residents were highly satisfied with the simulation curriculum.

CONCLUSIONS

Simulation-based education significantly improved resident knowledge and skill in the MICU. Knowledge acquired in the simulated environment was transferred to improved bedside skills caring for MICU patients. Simulation-based education is a valuable adjunct to standard clinical training for residents in the MICU.

Interdisciplinary team training identifies discrepancies in institutional policies and practices

The objective of this study was to evaluate the impact of an interdisciplinary team-training program in obstetric emergencies on identifying unsupportive institutional policies and systems-based practices. We implemented a qualitative study design with a purposive sample of interdisciplinary physicians, nurses, and ancillary allied health professionals from 4 specialties (n = 79) to conduct a 6-month, weekly simulation-based intervention for managing obstetric emergencies. Debriefing focused on identifying discrepancies between clinical practice and institutional policies. Our data yielded 5 categories of discrepancies between institutional or departmental policy and actual clinical practice. Specific institutional policies and system-based practices were recommended to health system administration for reevaluation. Simulation-based interdisciplinary team training can inform system-wide quality improvement objectives that could lead to increased patient safety.

Simulation in Otolaryngology

Simulation is revolutionizing medical education, certification, and ongoing professional development. Simulation encompasses a variety of technologies as well as nontechnical approaches to improve individual psychomotor skills, group effectiveness, and systems processes, all without direct risk to patients. Simulation-enhanced learning experiences, addressing learning objectives based on the needs of the individual or the group and following the principles of adult education, can be used to ensure consistent and comprehensive learning opportunities, thereby creatively complementing didactic and clinical learning experiences. Pockets of simulation expertise are already present in the field of otolaryngology; more will develop as these exciting and important innovations blossom.

Reducing the risk of shoulder dystocia and associated brachial plexus injury

Despite persisting controversy over shoulder dystocia prediction, prevention, and injury causation, the authors find considerable evidence in recent research in the field to recommend additional guidelines beyond the current American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines to improve clinical practice in managing patients at risk for experiencing shoulder dystocia. In this article, the authors offer health care providers information, practical direction, and advice on how to limit shoulder dystocia risk and, more importantly, to reduce adverse outcome risk.

Self-perceived impact of simulation-based training on the management of real-life obstetrical emergencies

OBJECTIVE

To evaluate the self-perceived impact of attending a simulation-based training course on the management of real-life obstetrical emergencies.

STUDY DESIGN

A prospective follow-up study was conducted. Obstetric nurses and obstetricians (n=54) from a tertiary care university hospital participated in a simulation-based training course for the management of four obstetric emergencies. One year after the last session of the course, participants were asked to complete a questionnaire evaluating the self-perceived impact it had on their knowledge, technical skills, and teamwork skills during experienced real-life situations. A five-point Likert grading scale was used. The χ(2) test with one degree of freedom or the Fisher's exact test were used to compare groups of participants. The t-test for independent samples was used to compare mean scores between groups.

RESULTS

A total of 46 healthcare professionals answered the questionnaire: 27 obstetricians and 19 obstetric nurses. Of these, 87% perceived an improvement (scores 4 or 5) in their knowledge and skills during real emergencies. Obstetric nurses expressed a significantly higher improvement than obstetricians in their ability to diagnose or be aware of obstetrical emergencies (p=0.002), in their technical skills (p=0.024), and in their ability to deal with teamwork related issues (p=0.005). Participants who had experienced in real-life situations all four simulated scenarios rated the impact of training significantly higher than others (p=0.049), and also reported a better improvement in their knowledge of management guidelines (p=0.006).

CONCLUSIONS

Healthcare professionals who participated in a simulation-based training course in obstetrical emergencies perceived a substantial improvement in their knowledge and skills when witnessing real-life emergencies. Improvements seem to be particularly relevant for obstetric nurses and for those who witness all trained obstetrical emergencies.

Medical simulation topic interests in a pediatric healthcare system

INTRODUCTION

Encouraged by evidence suggesting that simulation-based educational programs can translate to improved patient care, interest and investment in medical simulation have grown considerably in the past decade. Despite such growth, simulation is still a developing field, and little is known of the perceived needs for simulation training among practicing clinicians. This study describes medical simulation interests among clinicians in a pediatric health care system.

METHODS

A web-based survey addressing previous medical simulation experience, medical simulation interests, and demographics was distributed to physicians, nurses, and respiratory therapists within a pediatric healthcare system in the Delaware Valley.

RESULTS

All three groups expressed the highest level of interest in simulated resuscitation events ("mock codes") and the least interest in simulations involving communication and electronic medical records. "Airway problems" was identified as the most popular medical simulation topic of interest. Although the rank order of interest in medical simulation categories was similar across groups, physicians reported the lowest levels of interest in all simulation categories. Characteristics such as previous simulation experience and group (eg, nurses and respiratory therapists) were associated with medical simulation interests. Years in practice did not impact interest.

CONCLUSIONS

For adult learners, educational experiences should be targeted to the learners' perceived needs but should also address unrecognized deficits. Collectively, physicians, nurses, and respiratory therapists were most interested in participating in simulations addressing "codes" (emergency resuscitations) and airway management; these perceptions may provide a focus for designing simulation events that appeal to diverse learning styles. Prior experience with medical simulation seems to increase interest in subsequent simulation activities and offers the optimistic possibility that first-hand experience with simulation may help overcome structural and cultural barriers. Future research should seek to better understand potential obstacles for the participation of healthcare providers, especially physicians, in simulation-enhanced learning.

Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence

PURPOSE

This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education (SBME) with deliberate practice (DP).

METHOD

This is a quantitative meta-analysis that spans 20 years, 1990 to 2010. A search strategy involving three literature databases, 12 search terms, and four inclusion criteria was used. Four authors independently retrieved and reviewed articles. Main outcome measures were extracted to calculate effect sizes.

RESULTS

Of 3,742 articles identified, 14 met inclusion criteria. The overall effect size for the 14 studies evaluating the comparative effectiveness of SBME compared with traditional clinical medical education was 0.71 (95% confidence interval, 0.65-0.76; P < .001).

CONCLUSIONS

Although the number of reports analyzed in this meta-analysis is small, these results show that SBME with DP is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals. SBME is a complex educational intervention that should be introduced thoughtfully and evaluated rigorously at training sites. Further research on incorporating SBME with DP into medical education is needed to amplify its power, utility, and cost-effectiveness.

Advanced life support in obstetrics (ALSO) and post-partum hemorrhage: a prospective intervention study in Tanzania

OBJECTIVE

To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and the incidences of post-partum hemorrhage (PPH) at a regional hospital in Tanzania.

DESIGN

Prospective intervention study.

SETTING

A regional, referral hospital.

POPULATION

A total of 510 women delivered before and 505 after the intervention.

METHODS

All high- and mid-level providers involved in childbirth at the hospital attended a two-day ALSO provider course. Staff management was observed and post-partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training.

MAIN OUTCOME MEASURES

PPH (blood loss ≥500ml), severe PPH (blood loss ≥1000ml) and staff performance to prevent, detect and manage PPH.

RESULTS

The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 (95%CI: 0.44-0.69)], severe PPH from 9.2 to 4.3%[RR 0.47 (95%CI: 0.29-0.77)]. The active management of the third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. A significantly higher proportion of women with PPH had continuous uterine massage, oxytocin infusion and bimanual compression of the uterus after the training.

CONCLUSIONS

A two-day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short-term effects.

Simulation based learning in midwifery education: a systematic review

AIM

To critically examine the evidence for simulation based learning in midwifery education.

BACKGROUND

Simulated Learning Programs (SLPs) using low to high fidelity techniques are common in obstetric professionals' education and focus on the development of team work, labour and obstetric emergencies.

REVIEW METHODS

A systematic review incorporating critical appraisal approaches, setting clear objectives and a defined search and analysis strategy. Evidence from obstetrics, neonatology, technical and non-technical skills (teamwork) was included where it informed the development of midwifery curricula. Studies in English from 2000 to 2010 were included searching CINAHL Plus, OVID Medline, Cochrane, SCOPUS and ProQuest and Google Scholar.

RESULTS

Twenty-four papers were identified that met the inclusion criteria. All were quantitative reports; outcomes and levels of evidence varied with two notable papers indicating that simulation had an impact on clinical practice. Benefits of SLP over didactic formats were apparent, as were the development of non-technical skills confidence and competence. The study outcomes were limited by the range of evidence and context of the reports which focussed on obstetric emergency training using a number of simulation techniques.

CONCLUSION

There is evidence that simulated learning of midwifery skills is beneficial. Simulation learning has an educational and clinical impact and advantages over didactic approaches. Where clinical practice is infrequent i.e. obstetric emergencies, simulation is an essential component of curricula. Simulation enhances practice and therefore may reduce the time taken to achieve competence; however there is no evidence from the literature that simulation should replace clinical practice.

Elective course in acute care using online learning and patient simulation

OBJECTIVE

To enhance students' knowledge of and critical-thinking skills in the management of acutely ill patients using online independent learning partnered with high-fidelity patient simulation sessions.

DESIGN

Students enrolled in the Acute Care Simulation watched 10 weekly Web-based video presentations on various critical care and advanced cardiovascular pharmacotherapy topics. After completing each online module, all students participated in groups in patient-care simulation exercises in which they prepared a pharmacotherapeutic plan for the patient, recommended this plan to the patient's physician, and completed a debriefing session with the facilitator.

ASSESSMENT

Students completed a pretest and posttest before and after each simulation exercise, as well as midterm and final evaluations and a satisfaction survey. Pharmacy students significantly improved their scores on 9 of the 10 tests (p ≤ 0.05). Students' performance on the final evaluation improved compared with performance on the midterm evaluation. Overall, students were satisfied with the unique dual approach to learning and enjoyed the realistic patient-care environment that the simulation laboratory provided.

CONCLUSION

Participation in an elective course that combined self-directed Web-based learning and hands-on patient simulation exercises increased pharmacy students' knowledge and critical-thinking skills in acute care.

The case for OBLS: a simulation-based obstetric life support program

Errors by health care professionals result in significant patient morbidity and mortality, and the labor and delivery ward is one of the highest risk areas in the hospital. Parturients today are of higher acuity than anytime previously, and maternal mortality is increasing. Obstetrical staff must therefore be familiar with emergency protocols geared to the maternal-fetal dyad. However, the medical literature suggests that obstetrical providers are not optimally trained to render care during maternal cardiopulmonary arrest. We describe the evolution of immersive learning and simulation in the Neonatal Resuscitation Program, and suggest the development of a multidisciplinary team, simulation-enhanced obstetric crisis training program (OBLS) may likewise benefit obstetrical health care professionals. OBLS would emphasize high quality basic life support, uterine displacement, use of an automatic external defibrillator, and delivery of the fetus within 5 minutes of maternal arrest should resuscitative efforts prove ineffective.

Effects of shoulder dystocia training on the incidence of brachial plexus injury

OBJECTIVE

We sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI).

STUDY DESIGN

After implementing training for maternity staff, the incidence of OBPI was compared between pretraining and posttraining periods using both univariate and multivariate analyses in deliveries complicated by shoulder dystocia.

RESULTS

The overall incidence of OBPI in vaginal deliveries decreased from 0.40% pretraining to 0.14% posttraining (P < .01). OBPI after shoulder dystocia dropped from 30% to 10.67% posttraining (P < .01). Maternal body mass index (P < .01) and neonatal weight (P = .02) decreased and head-to-body delivery interval increased in the posttraining period (P = .03). Only shoulder dystocia training remained associated with reduced OBPI (P = .02) after logistic regression analysis. OBPI remained less in the posttraining period (P = .01), even after excluding all neonates with birthweights >2 SD above the mean.

CONCLUSION

Shoulder dystocia training was associated with a lower incidence of OBPI and the incidence of OBPI in births complicated by shoulder dystocia.

The use of simulation to teach clinical skills in obstetrics

Obstetrical practice demands sensitivity, clinical skill, and acumen. Obstetrical emergencies are rare occurrences and are most appropriately dealt with by experienced staff. Simulation provides an opportunity to gain this experience without patient risk and furthermore builds confidence and satisfaction amongst learners. There is an abundance of evidence to show the effectiveness of simulation training. Simulation has been demonstrated to reduce errors, increase knowledge, skills, communication and team working, and improve perinatal outcomes. Further research to measure the effect of training to identify what works, where and at what cost is needed. We explore the evidence for the use of simulation-based training across a broad range of obstetrical emergencies, promote collaboration amongst disciplines and discuss the formal introduction of simulation training into a curriculum. Reducing preventable harm in obstetrics is a priority for families and society at large and this article endeavors to highlight the role that simulation has to play.

Neonatal brachial plexus injury: comparison of incidence and antecedents between 2 decades

OBJECTIVE

We sought to compare the incidence and antecedents of neonatal brachial plexus injury (BPI) in 2 different 5-year epochs a decade apart following the introduction of specific staff training in the management of shoulder dystocia.

STUDY DESIGN

All infants with BPI were prospectively identified during 2004 through 2008. Injuries were correlated with maternal details and intrapartum events and compared with the earlier series.

RESULTS

Of 41,828 deliveries during 2004 through 2008, 72 infants with BPI were identified (1.7/1000), compared to 54 cases (1.5/1000) from 1994 through 1998 (P = .4); 9 injuries (12.5%) were persistent from 2004 through 2008, compared with 10 (18.5%) earlier (P = .4). There were no significant differences between the 2 time periods with respect to maternal parity, obesity, or prolonged pregnancy, although the cesarean section rate had increased from 10.7 to 18.4%.

CONCLUSION

Despite training in the management of shoulder dystocia and a rising institutional cesarean section rate, the incidence of BPI has remained unchanged compared with 10 years earlier.

Simulation in emergency medicine training

Simulation provides a range of educational tools that have increasingly been incorporated into emergency medicine (EM) curricula. Standardized patients and some partial task trainers, such as intubation heads, have been used for decades. More recently, a growing number of computer-screen simulations, high-fidelity mannequins, and virtual-reality simulators have expanded the number of procedures and conditions, which can be effectively simulated.The Accreditation Council for Graduate Medical Education transitioned to a competency-based assessment of residency programs in 2001 and included simulation as a method for incorporating the 6 core competencies into graduate medical education curricula. Over the past decade, numerous peer-reviewed publications have promoted simulation as an effective educational tool for each of the core competencies.The advanced technology used to operate many current simulators can erroneously become the focus of efforts to create a simulation-based curriculum. Simulation can most effectively be incorporated into EM curricula through the use of time-proven concepts, which start with defining the targeted learners, assessing their general and specific educational needs, defining learning objectives, and selecting the best educational strategy for achieving each objective. In many, but not all, instances, simulation can be the best tool for achieving EM learning objectives.

Evaluation of force applied during deliveries complicated by shoulder dystocia using simulation

OBJECTIVE

We sought to objectively evaluate the amount of force applied during deliveries complicated by shoulder dystocia among different providers.

STUDY DESIGN

Providers who do deliveries at our institution were approached for participation. The simulation exercise used a childbirth mannequin that measures the amount of force the provider applies to the fetal head during delivery. The amount of force applied and information regarding the provider's level of experience, height, weight, and gender was recorded. This study was approved by the hospital institutional review board.

RESULTS

A total of 47 providers participated. The mean force applied during each situation was not associated with the provider's experience, height, weight, or gender.

CONCLUSION

Provider experience, gender, and body habitus were not associated with the amount of force applied during delivery. We found differences between family medicine and obstetrics/gynecology providers. In addition, a significant number of all providers (19/47, 40%) pulled >100 N.

Simulation and quality improvement in anesthesiology

Simulation, a strategy for improving the quality and safety of patient care, is used for the training of technical and nontechnical skills and for training in teamwork and communication. This article reviews simulation-based research, with a focus on anesthesiology, at 3 different levels of outcome: (1) as measured in the simulation laboratory, (2) as measured in clinical performance, and (3) as measured in patient outcomes. It concludes with a discussion of some current uses of simulation, which include the identification of latent failures and the role of simulation in continuing professional practice assessment for anesthesiologists.

Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross-sectional study

OBJECTIVE

To identify specific aspects of teamworking associated with greater clinical efficiency in simulated obstetric emergencies.

DESIGN

Cross-sectional secondary analysis of video recordings from the Simulation & Fire-drill Evaluation (SaFE) randomised controlled trial.

SETTING

Six secondary and tertiary maternity units.

SAMPLE

A total of 114 randomly selected healthcare professionals, in 19 teams of six members.

METHODS

Two independent assessors, a clinician and a language communication specialist identified specific teamwork behaviours using a grid derived from the safety literature.

MAIN OUTCOME MEASURES

Relationship between teamwork behaviours and the time to administration of magnesium sulfate, a validated measure of clinical efficiency, was calculated.

RESULTS

More efficient teams were likely to (1) have stated (recognised and verbally declared) the emergency (eclampsia) earlier (Kendall's rank correlation coefficient τ(b) = -0.53, 95% CI from -0.74 to -0.32, P=0.004); and (2) have managed the critical task using closed-loop communication (task clearly and loudly delegated, accepted, executed and completion acknowledged) (τ(b) = 0.46, 95% CI 0.17-0.74, P=0.022). Teams that administered magnesium sulfate within the allocated time (10 minutes) had significantly fewer exits from the labour room compared with teams who did not: a median of three (IQR 2-5) versus six exits (IQR 5-6) (P=0.03, Mann-Whitney U-test).

CONCLUSIONS

Using administration of an essential drug as a valid surrogate of team efficiency and patient outcome after a simulated emergency, we found that more efficient teams were more likely to exhibit certain team behaviours relating to better handover and task allocation.

Moral imagination in simulation-based communication skills training

Clinical simulation is used in nursing education and in other health professional programs to prepare students for future clinical practice. Simulation can be used to teach students communication skills and how to deliver bad news to patients and families. However, skilled communication in clinical practice requires students to move beyond simply learning superficial communication techniques and behaviors. This article presents an unexplored concept in the simulation literature: the exercise of moral imagination by the health professional student. Drawing from the works of Hume, Aristotle and Gadamer, a conceptualization of moral imagination is first provided. Next, this article argues that students must exercise moral imagination on two levels: towards the direct communication exchange before them; and to the representative nature of simulation encounters. Last, the limits of moral imagination in simulation-based education are discussed.