Evaluation of simulation-based training on the ability of birth attendants to correctly perform bimanual compression as obstetric first aid

Simulation-Based Training in Emergency Obstetric Care in Sub-Saharan and Central Africa: A Scoping Review

Background

Every day approximately 810 women die from complications related to pregnancy and childbirth worldwide. Around two thirds of these deaths happen in sub-Saharan Africa. One of the strategies to decrease these numbers is improving the quality of care by emergency obstetric simulation-based training. The effectiveness of such training programs depends on the program's instructional design.

Objective

This review gives an overview of studies about emergency obstetric simulation-based training and examines the applied instructional design of the training programs in sub-Saharan and Central Africa.

Methods

We searched Medline, Embase and Cochrane Library from inception to May 2021. Peer-reviewed articles on emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa were included. Outcome measures were categorized based on Kirkpatrick's levels of training evaluation. The instructional design was evaluated by using the ID-SIM questionnaire.

Findings

In total, 47 studies met the inclusion criteria. Evaluation on Kirkpatrick level 1 showed positive reactions in 18 studies. Challenges and recommendations were considered. Results on knowledge, skills, and predictors for these results (Kirkpatrick level 2) were described in 29 studies. Retention as well as decay of knowledge and skills over time were presented. Results at Kirkpatrick level 3 were measured in 12 studies of which seven studies demonstrated improvements of skills on-the-job. Improvements of maternal and neonatal outcomes were described in fifteen studies and three studies reported on cost-estimations for training rollout (Kirkpatrick level 4). Instructional design items were heterogeneously applied and described.

Conclusions

Results of 47 studies indicate evidence that simulation-based training in sub-Saharan and Central Africa can have a positive impact across all four levels of Kirkpatrick's training evaluation model. However, results were not consistent across all studies and the effects vary over time. A detailed description of instructional design features in future publications on simulation-based training will contribute to a deeper understanding of the underlying mechanisms that determine why certain training programs are more effective in improving maternal and neonatal healthcare outcomes than other.

Simulation and nurse-mentoring in a statewide nurse mentoring program in Bihar, India: diagnosis of postpartum hemorrhage and intrapartum asphyxia

Background: Mentoring programs that include simulation, bedside mentoring, and didactic components are becoming increasingly popular to improve quality. These programs are designed with little evidence to inform the optimal composition of mentoring activities that would yield the greatest impact on provider skills and patient outcomes. We examined the association of number of maternal and neonatal emergency simulations performed with the diagnosis of postpartum hemorrhage (PPH) and intrapartum asphyxia in real patients. Methods: We used a prospective cohort and births were compared between- and within-facility over time. Setting included 320 public facilities in the state of Bihar, India May 2015 - 2017. The participants were deliveries and livebirths. The interventions carried out were mobile nurse-mentoring program with simulations, teamwork and communication activities, didactic teaching, demonstrations of clinical procedures and bedside mentoring including conducting deliveries. Nurse mentor pairs visited each facility for one week, covering four facilities over a four-week period, for seven to nine consecutive months. The outcome measures were diagnosis of PPH and intrapartum asphyxia. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Conclusions: Findings suggest a complex relationship between performing simulations and opportunities for direct practice with patients, and there may be an optimal balance in performing the two that would maximize diagnosis of PPH and intrapartum asphyxia.

Improving the recognition and management of hemorrhage: A scoping review of nursing and midwifery education

BACKGROUND

Hemorrhage is a frequent complication that nurses and midwives must recognize and manage to avoid life-threatening consequences for patients. There is currently no synthesis of evidence on educational interventions in nursing and midwifery regarding hemorrhage, thus limiting the definition of best practices.

OBJECTIVE

To map the literature on nursing and midwifery education regarding the recognition and management of hemorrhage.

DESIGN

Scoping review based on the Joanna Briggs Institute guidelines.

DATA SOURCES

Quantitative studies evaluating the effect of educational interventions with students, nurses, or midwives published in English or French, with no time limit.

REVIEW METHODS

Study selection, data extraction, and quality assessment were conducted by two independent reviewers. We characterized educational interventions based on the Guideline for Reporting Evidence-Based Practice Educational Interventions and Teaching. We categorized learning outcomes using the New World Kirkpatrick Model. Methodological quality appraisal was performed with tools from the Joanna Briggs Institute. Findings were synthesized using descriptive statistics and graphical methods RESULT: Most of the 38 studies used a single-group design (n = 26, 68%) and were conducted with professionals (n = 28, 74%) in hospital settings (n = 20, 53%). Most were of low (n = 14; 37%) or moderate (n = 18, 47%) methodological quality. Most interventions focused on postpartum hemorrhage (n = 34, 89%) and combined two or more teaching strategies (n = 25, 66%), often pairing an informational segment (e.g., lecture, readings) with a practical session (e.g., workshop, simulation). Learning outcomes related to the management (n = 27; 71%) and recognition of hemorrhage (n = 19, 50%), as well as results for patients and organizations (n = 9, 24%).

CONCLUSION

Considerable heterogeneity in interventions and learning outcomes precluded conducting a systematic review of effectiveness. High-quality, controlled studies are needed, particularly in surgery and trauma. Reflection on the contribution of nurses and midwives to the detection, monitoring, and management of hemorrhage could enrich the content and expected outcomes of hemorrhage education.

Risk factors of uterine contraction after ureteroscopy in pregnant women with renal colic

Background

Ureteroscopy is widely applied in pregnant women with renal colic, but such patients are easy to experience uterine contraction after surgery. There are many factors which may affect uterine contraction, this study aims to explore the risk factors of uterine contraction triggered by ureteroscopy in pregnant women with renal colic.

Methods

One hundred and one pregnant women were retrospectively analyzed, the patients were hospitalized because of severe renal colic. All patients received ureteroscopy during which double J catheters were inserted into ureters for drainage. Patients received other medical treatments individually according to their condition and uterine contractions were detected by EHG within 12 h after operation. Patients were classified as group A (uterine contraction) and group B (no uterine contraction) according to the presence or absence of continuously regular uterine contraction. Clinical characteristics were collected for further analysis, including history of childbirth, anesthesia method, application of phloroglucinol or not, operation time, Oxygen inhalation or not, pain relief or not after surgery, systemic inflammatory response syndrome (SIRS) occurred or not. A binary logistic regression analysis model was established to explore whether such clinical characteristics were relevant to uterine contraction after ureteroscopy.

Results

Continuously regular uterine contraction presented in 46 pregnant women within 12 h after ureteroscopy, making the incidence of uterine contraction as high as 45.54%. The presence of uterine contraction was related to the following factors(P < 0.05): history of childbirth (primipara versus multipara)(OR 6.593, 95% CI 2.231–19.490), operation time (each quarter additional) (OR 2.385, 95% CI 1.342–4.238), application of phloroglucinol (yes versus not) (OR 6.959, 95% CI 1.416–34.194), pain relief after surgery(yes versus not)(OR 6.707, 95% CI 1.978–22.738), SIRS occurred after surgery (yes versus not) (OR 0.099, 95% CI 0.014–0.713).

Conclusion

Continuously regular uterine contraction is easy to occur within 12 h after ureteroscopy in pregnant women. SIRS occurred after surgery is a risk factor for uterine contraction; on the contrary, no history of childbirth, shorter operation time, application of phloroglucinol, pain relief after surgery are protective factors.

Evaluating the Instructional Design and Effect on Knowledge, Teamwork, and Skills of Technology-Enhanced Simulation-Based Training in Obstetrics in Uganda: Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Simulation-based training is a common strategy for improving the quality of facility-based maternity services and is often evaluated using Kirkpatrick's theoretical model. The results on the Kirkpatrick levels are closely related to the quality of the instructional design of a training program. The instructional design is generally defined as the "set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes."

OBJECTIVE

The aim of this study is to evaluate the instructional design of a technology-enhanced simulation-based training in obstetrics, the reaction of participants, and the effect on knowledge, teamwork, and skills in a low-income country.

METHODS

A stepped-wedge cluster randomized trial was performed in a university hospital in Kampala, Uganda, with an annual delivery volume of over 31,000. In November 2014, a medical simulation center was installed with a full-body birthing simulator (Noelle S550, Gaumard Scientific), an interactive neonate (Simon S102 Newborn CPR Simulator, Gaumard Scientific), and an audio and video recording system. Twelve local obstetricians were trained and certified as medical simulation trainers. From 2014 to 2016, training was provided to 57 residents in groups of 6 to 9 students. Descriptive statistics were calculated for ten instructional design features of the training course measured by the 42-item ID-SIM (Instructional Design of a Simulation Improved by Monitoring). The Wilcoxon signed rank test was conducted to investigate the differences in scores on knowledge, the Clinical Teamwork Scale, and medical technical skills.

RESULTS

The mean scores on the ten instructional design features ranged from 54.9 (95% CI 48.5-61.3) to 84.3 (95% CI 80.9-87.6) out of 100. The highest mean score was given on the feature feedback and the lowest scores on repetitive practice and controlled environment. The overall score for the training day was 92.8 out of 100 (95% CI 89.5-96.1). Knowledge improved significantly, with a test score of 63.4% (95% CI 60.7-66.1) before and 78.9% (95% CI 76.8-81.1) after the training (P<.001). The overall score on the 10-point Clinical Teamwork Scale was 6.0 (95% CI 4.4-7.6) before and 5.9 (95% CI 4.5-7.2) after the training (P=.78). Medical technical skills were scored at 55.5% (95% CI 47.2-63.8) before and 65.6% (95% CI 56.5-74.7) after training (P=.08).

CONCLUSIONS

Most instructional design features of a technology-enhanced simulation-based training in obstetrics in a low-income country were scored high, although intervals were large. The overall score for the training day was high, and knowledge did improve after the training program, but no changes in teamwork and (most) medical technical skills were found. The lowest-scored instructional design features may be improved to achieve further learning aims.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN98617255; http://www.isrctn.com/ISRCTN98617255.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12884-020-03050-3.

The state of emergency medical technician education in Ghana

Objective

The National Ambulance Service (NAS) provides emergency medical services throughout Ghana and trains emergency medical technicians (EMTs) at the NAS Prehospital Emergency Care Training School (PECTS). Currently the majority of EMT training occurs primarily in a traditional didactic format. Students and faculty were interviewed to better understand their views of the current curriculum. Additionally, any barriers to integration of simulation-based learning were assessed. Following the interviews, the faculty was trained to conduct obstetric and neonatal simulations. The faculty was then observed introducing the simulations to the EMT students.

Methods

A standardized list of questions developed in consultation with an education expert was used to elicit student and faculty expression of opinion. Interviews were conducted in-person in small group settings. Training sessions were conducted in-person in large group settings.

Results

Students and faculty alike expressed pride in their work and 14/25 groups felt that teaching efforts were high. However, students verbalized concern involving their lack of rest (12/18) and the high volume of lectures per day (11/18). Both students and faculty felt limited by the lack of simulation tools (17/25), library resources (14/25), internet access (17/25), and infrastructure (20/25). All groups felt favorably towards the integration of simulation-based learning (25/25).

Conclusion

The faculty and students of PECTS support the transition from a curriculum based on traditional didactic learning to one based on simulation learning.

Study protocol training for life: a stepped wedge cluster randomized trial about emergency obstetric simulation-based training in a low-income country

BACKGROUND

Globally perinatal and maternal mortality rates remain unacceptably high. There is increasing evidence that simulation-based training in obstetric emergencies is associated with improvement in clinical outcomes. However, the results are not entirely consistent. The need for continued research in a wide variety of clinical settings to establish what works, where and why was recommended. The aim of this study is to investigate the effectiveness of an emergency obstetric simulation-based training program with medical technical and teamwork skills on maternal and perinatal mortality in a low-income country.

METHODS

A stepped wedge cluster randomized trial will be conducted at the medium to high-risk labour ward at Mulago Hospital, Kampala, Uganda, with an annual delivery rate of over 23,000. The training will be performed using a train-the-trainers model in which training is cascaded down from master trainers to local facilitators (gynaecologists) to learners (senior house officers). Local facilitators will be trained during a four-day train-the-trainers course with an annual repetition. The senior house officers will be naturally divided in seven clusters and randomized for the moment of training. The training consists of a one-day, monodisciplinary, simulation-based training followed by repetition training sessions. Scenarios are based on the main local causes of maternal and neonatal mortality and focus on both medical technical and crew resource management skills. Kirkpatrick's classification will be used to evaluate the training program. Primary outcome will be the composite of maternal and neonatal mortality ratios. Secondary outcome will comprise course perception, evaluation of the instructional design of the training, knowledge, technical skills, team performance, percentage of ventouse deliveries, percentage of caesarean sections, and a Weighted Adverse Outcome Score.

DISCUSSION

This stepped wedge cluster randomized trial will investigate the effect of a monodisciplinary simulation-based obstetric training in a low-income country, focusing on both medical technical skills and crew resource management skills, on patient outcome at one of the largest labour wards worldwide. We will use a robust study design which will allow us to better understand the training effects, and difficulties in evaluating training programs in low-income countries.

TRIAL REGISTRATION

ISRCTN98617255 , retrospectively registered July 23, 2018.

Rapid cycle deliberate practice vs. traditional simulation in a resource-limited setting

BACKGROUND

We sought to develop a low-fidelity simulation-based curriculum for pediatric residents in Rwanda utilizing either rapid cycle deliberate practice (RCDP) or traditional debriefing, and to determine whether RCDP leads to greater improvement in simulation-based performance and in resident confidence compared with traditional debriefing.

METHODS

Pediatric residents at the Centre Hospitalier Universitaire de Kigali (CHUK) were randomly assigned to RCDP or traditional simulation and completed a 6 month-long simulation-based curriculum designed to improve pediatric resuscitation skills. Pre- and post- performance was assessed using a modified version of the Simulation Team Assessment Tool (STAT). Each video-taped simulation was reviewed by two investigators and inter-rater reliability was assessed. Self-confidence in resuscitation, pre- and post-simulation, was assessed by Likert scale survey. Analyses were conducted using parametric and non-parametric testing, ANCOVA and intra-class correlation coefficients (ICC).

RESULTS

There was a 21% increase in pre- to post-test performance in both groups (p < 0.001), but no difference between groups (mean difference - 0.003%; p 0.94). Inter-rater reliability was exceptional with both pre and post ICCs ≥0.95 (p < 0.001). Overall, self-confidence scores improved from pre to post (24.0 vs. 30.0 respectively, p < 0.001), however, the there was no difference between the RCDP and traditional groups.

CONCLUSIONS

Completion of a six-month low-fidelity simulation-based curriculum for pediatric residents in Rwanda led to statistically significant improvement in performance on a simulated resuscitation. RCDP and traditional low-fidelity simulation-based instruction may both be valuable tools to improve resuscitation skills in pediatric residents in resource-limited settings.

Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis

BACKGROUND

Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low, and lower-middle income countries (LMIC) and needs to be underpinned by effective education. There is considerable variation in the quality of midwifery education provided globally.

OBJECTIVE

To determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care.

DESIGN

Rapid Systematic Evidence Review METHODS: A systematic search of the following databases was conducted: Medline, CINAHL, LILACs, PsycInfo, ERIC, and MIDIRs. Studies that evaluated the effects of pre-service and in-service education that were specifically designed to train, educate or upskill care providers in order to provide quality maternal and newborn care were included. Data was extracted and presented narratively.

FINDINGS

Nineteen studies were included in the review. Of these seven were evaluations of pre-service education programmes and 12 were evaluations of in-service education programmes. Whilst studies demonstrated positive effects on knowledge and skills, there was a lack of information on whether this translated into behaviour change and positive effects for women and babies. Moreover, the level of the evidence was low and studies often lacked an educational framework and theoretical basis. Mapping the skills taught in each of the programmes to the Quality Maternal and Newborn Care framework (Renfrew et al., 2014) identified that interventions focused on very specific or individual clinical skills and not on the broader scope of midwifery.

KEY CONCLUSIONS

There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs; this is at odds with the importance of the topic to survival, health and well-being. There is a preponderance of studies which focus on training for specific emergencies during labour and birth. None of the in-service programmes considered the education of midwives to international standards with the full scope of competencies needed. There is an urgent need for the development of theoretically informed pre-service and in-service midwifery education programmes, and well-conducted evaluations of such programmes. Upscaling quality midwifery care for all women and newborn infants is of critical importance to accelerate progress towards Sustainable Development Goal 3. Quality midwifery education is an essential pre-requisite for quality care. To deliver SDG 3, the startling underinvestment in midwifery education identified in this review must be reversed.

An Evaluation of the Role of Simulation Training for Teaching Surgical Skills in Sub-Saharan Africa

Background

An estimated 5 billion people worldwide lack access to any surgical care, whilst surgical conditions account for 11–30% of the global burden of disease. Maximizing the effectiveness of surgical training is imperative to improve access to safe and essential surgical care on a global scale. Innovative methods of surgical training have been used in sub-Saharan Africa to attempt to improve the efficiency of training healthcare workers in surgery. Simulation training may have an important role in up-scaling and improving the efficiency of surgical training and has been widely used in SSA. Though not intended to be a systematic review, the role of simulation for teaching surgical skills in Sub-Saharan Africa was reviewed to assess the evidence for use and outcomes.

Methods

A systematic search strategy was used to retrieve relevant studies from electronic databases PubMed, Ovid, Medline for pertinent articles published until August 2016. Studies that reported the use of simulation-based training for surgery in Africa were included.

Results

In all, 19 articles were included. A variety of innovative surgical training methods using simulation techniques were identified. Few studies reported any outcome data. Compared to the volume of surgical training initiatives that are known to take place in SSA, there is very limited good quality published evidence for the use of simulation training in this context.

Conclusions

Simulation training presents an excellent modality to enhance and improve both volume and access to high quality surgical skills training, alongside other learning domains. There is a desperate need to meticulously evaluate the appropriateness and effectiveness of simulation training in SSA, where simulation training could have a large potential beneficial impact. Training programs should attempt to assess and report learner outcomes.

Measuring movement towards improved emergency obstetric care in rural Kenya with implementation of the PRONTO simulation and team training program

As the proportion of facility-based births increases, so does the need to ensure that mothers and their newborns receive quality care. Developing facility-oriented obstetric and neonatal training programs grounded in principles of teamwork utilizing simulation-based training for emergency response is an important strategy for improving the quality care. This study uses 3 dimensions of the Kirkpatrick Model to measure the impact of PRONTO International (PRONTO) simulation-based training as part of the Linda Afya ya Mama na Mtoto (LAMMP, Protect the Health of mother and child) in Kenya. Changes in knowledge of obstetric and neonatal emergency response, self-efficacy, and teamwork were analyzed using longitudinal, fixed-effects, linear regression models. Participants from 26 facilities participated in the training between 2013 and 2014. The results demonstrate improvements in knowledge, self-efficacy, and teamwork self-assessment. When comparing pre-Module I scores with post-training scores, improvements range from 9 to 24 percentage points (p values < .0001 to .026). Compared to baseline, post-Module I and post-Module II (3 months later) scores in these domains were similar. The intervention not only improved participant teamwork skills, obstetric and neonatal knowledge, and self-efficacy but also fostered sustained changes at 3 months. The proportion of facilities achieving self-defined strategic goals was high: 95.8% of the 192 strategic goals. Participants rated the PRONTO intervention as extremely useful, with an overall score of 1.4 out of 5 (1, extremely useful; 5, not at all useful). Evaluation of how these improvements affect maternal and perinatal clinical outcomes is forthcoming.

Effectiveness of mHealth Interventions Targeting Health Care Workers to Improve Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Low- and middle-income countries (LMICs) face the highest burden of maternal and neonatal deaths. Concurrently, they have the lowest number of physicians. Innovative methods such as the exchange of health-related information using mobile devices (mHealth) may support health care workers in the provision of antenatal, delivery, and postnatal care to improve maternal and neonatal outcomes in LMICs.

OBJECTIVE

We conducted a systematic review evaluating the effectiveness of mHealth interventions targeting health care workers to improve maternal and neonatal outcomes in LMIC.

METHODS

The Cochrane Library, PubMed, EMBASE, Global Health Library, and Popline were searched using predetermined search and indexing terms. Quality assessment was performed using an adapted Cochrane Risk of Bias Tool. A strength, weakness, opportunity, and threat analysis was performed for each included paper.

RESULTS

A total of 19 studies were included for this systematic review, 10 intervention and 9 descriptive studies. mHealth interventions were used as communication, data collection, or educational tool by health care providers primarily at the community level in the provision of antenatal, delivery, and postnatal care. Interventions were used to track pregnant women to improve antenatal and delivery care, as well as facilitate referrals. None of the studies directly assessed the effect of mHealth on maternal and neonatal mortality. Challenges of mHealth interventions to assist health care workers consisted mainly of technical problems, such as mobile network coverage, internet access, electricity access, and maintenance of mobile phones.

CONCLUSIONS

mHealth interventions targeting health care workers have the potential to improve maternal and neonatal health services in LMICs. However, there is a gap in the knowledge whether mHealth interventions directly affect maternal and neonatal outcomes and future research should employ experimental designs with relevant outcome measures to address this gap.

An innovative approach to in-service training of maternal health staff in Cambodian hospitals

OBJECTIVE

To demonstrate the feasibility of implementing evidence-based continuing medical education (CME) to improve key skills among maternity staff in Cambodia.

METHODS

A skills-based CME program was implemented in 33 Cambodian hospitals. Each clinical skills practice (CSP) module consisted of a 1-day practice session, focusing on three maternal and newborn interventions, followed by support visits to participating hospitals. Skills were assessed at 27 intervention hospitals and five control hospitals 7-11 months after the practice sessions through observation of neonatal resuscitation, magnesium sulfate dilution, and aortic compression simulations.

RESULTS

A total of 559 healthcare workers attended at least one CSP practice session. The skills assessment included 47 doctors and 210 midwives. Hospital staff who participated in CSP performed significantly better than did those from control hospitals on neonatal resuscitation (mean score 31.22 vs 17.00; P<0.001), magnesium sulfate dilution (mean score 11.01 vs 8.47; P<0.001), and aortic compression (mean score 13.87 vs 4.33; P<0.001). CSP participants were also significantly more likely to score higher than the 70% cutoff for neonatal resuscitation and magnesium sulfate dilution than were those from control hospitals, after adjustment for hospital level and profession (P≤0.05).

CONCLUSION

Key clinical skills in low-resource settings can be improved by implementing CME using simulations and supportive follow-up.

Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators

BACKGROUND

Ineffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators.

METHODS

Data was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement.

RESULTS

A total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p <0.001- 0.009) in all domains. Teamwork scores improved and were maintained over a three month period. A mean of 58.8% strategic planning goals per team in each hospital were achieved. There was no association between high goal achievement and knowledge, self-efficacy, proportion of doctors or nurses in training, state, or teamwork score.

CONCLUSIONS

These results suggest that PRONTO's highly realistic, locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in resource-limited settings.

TRIAL REGISTRATION

NCT01477554.

Simulation training improves clinical knowledge of major haemorrhage management in foundation year doctors

OBJECTIVES

(i) To develop a major haemorrhage simulation training programme. (ii) To design an assessment tool to measure the effectiveness of this programme. (iii) To use simulation training to create more effective protocols.

BACKGROUND

Major haemorrhage is a time-critical medical emergency that can be faced by every Foundation Year (FY) doctor. Standard methods of teaching provide limited opportunity for junior doctors to improve their knowledge and practical skills for major haemorrhage situations. Simulation is increasingly used in medical training but has not been used as a means both to facilitate learning and refine hospital major haemorrhage policy.

METHODS

The effect of major haemorrhage simulation on attendees' learning was compared to a comparator group not exposed to simulation. Questionnaire pre-simulation and 3 months post-simulation training assessed knowledge of the Trust Major Haemorrhage Protocol (MHP).

RESULTS

Sixteen FY1 doctors attended simulation training. The comparator group included 47 FY1 doctors. No significant difference was found between simulation and comparator groups on baseline questionnaire scores. The simulation group showed significant improvement (total score, mean standard deviation (SD) pre-test 27.15 (4.02), post-test 39.13 (3.91), p < 0.001). The comparator group showed no significant change (total score, pre-test 25.06 (5.70), post-test 23.54 (6.85), p = 0.33) (19 lost to follow up). The study resulted in the production of a new MHP.

CONCLUSION

This study has demonstrated that simulation training improved doctors' knowledge in major haemorrhage management and that the experience of observing the simulation training allowed senior staff to undertake analysis and improvement of an existing MHP.

Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting

OBJECTIVE

To evaluate "Helping Mothers Survive Bleeding After Birth" (HMS BAB) simulation-based training in a low-resource setting.

DESIGN

Educational intervention study.

SETTING

Rural referral hospital in Northern Tanzania.

POPULATION

Clinicians, nurse-midwives, medical attendants, and ambulance drivers involved in maternity care.

METHODS

In March 2012, health care workers were trained in HMS BAB, a half-day simulation-based training, using a train-the-trainer model. The training focused on basic delivery care, active management of third stage of labor, and treatment of postpartum hemorrhage, including bimanual uterine compression.

MAIN OUTCOME MEASURES

Evaluation questionnaires provided information on course perception. Knowledge, skills, and confidence of facilitators and learners were tested before and after training.

RESULTS

Four master trainers trained eight local facilitators, who subsequently trained 89 learners. After training, all facilitators passed the knowledge test, but pass rates for the skills test were low (29% pass rate for basic delivery and 0% pass rate for management of postpartum hemorrhage). Evaluation revealed that HMS BAB training was considered acceptable and feasible, although more time should be allocated for training, and teaching materials should be translated into the local language. Knowledge, skills, and confidence of learners increased significantly immediately after training. However, overall pass rates for skills tests of learners after training were low (3% pass rate for basic delivery and management of postpartum hemorrhage).

CONCLUSIONS

The HMS BAB simulation-based training has potential to contribute to education of health care providers. We recommend a full day of training and validation of the facilitators to improve the training.

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.