Improving Neonatal Outcome Through Practical Shoulder Dystocia Training

Simulation based education in paediatric resuscitation

There is increasing use of clinical Simulation Based Education (SBE) in healthcare due to an increased focus on patient safety, the call for a new training model not based solely on apprenticeship, a desire for standardised educational opportunities that are available on-demand, and a need to practice and hone skills in a controlled environment. SBE programs should be evaluated against Kirkpatrick level 3 or 4 criteria to ensure they improve patient or staff outcomes in the real world. SBE programs have been shown to improve outcomes in neonatology - reductions in hypoxic ischaemic encephalopathy, in brachial plexus injury, rates of school age cerebral palsy, reductions in 24hr mortality and improvements in first pass intubation rates. In paediatrics SBE programs have shown improvements in paediatric cardiac arrest survival, PICU survival, reduced PICU admissions, reduced PICU length of stay and reduced time to critical operations. SBE can improve the non-technical tasks of teamwork, leadership and communication (within the team and with patients and carers). Simulation is a useful tool in Quality and Safety and is used to identify latent safety issues that can be addressed by future programs. In high stakes assessment simulation can be a mode of assessment, however, care needs to be taken to ensure the tool is validated carefully.

The improvement and retention of skills in shoulder dystocia management with the use of high-fidelity simulation: The SAFE (SimulAtion high-FidElity) study

BACKGROUND

Shoulder dystocia is a relatively uncommon but serious childbirth-related emergency.

AIM

To explore the improvement and retention of skills in shoulder dystocia management through high-fidelity simulation training.

METHODS

The SAFE (SimulAtion high-FidElity) study was a prospective cohort study that utilised a high-fidelity birth simulator. Registered midwives and final year midwifery students were invited to participate in a one-day workshop at 6-monthly intervals. There was a 30-minute initial assessment, a 30-minute theoretical and hands-on training, and a 30-minute post-training assessment on shoulder dystocia management. Pre-training and post-training values for the predetermined outcomes were compared. In each workshop we assessed the proportion of successful simulated births, the performance of manoeuvres to manage shoulder dystocia, the head-to-body birth time, the fetal head traction force, the quality of communication, the perception of time-to-birth, and the self-reported confidence levels.

FINDINGS

The baseline workshop recruited 101 participants that demonstrated a significant increase in the proportion of successful simulated births (8.9% vs 93.1%), and a two-fold to three-fold increase in the score of manoeuvres, communication, and confidence after training. Those with low pre-training levels of competency and confidence improved the most post-training at baseline. There was a retention of manoeuvres, communication skills and confidence at 6 months. There was no reduction in fetal head traction force over time. Those being proficient before initial training retained and performed best at the 6-month follow-up.

CONCLUSION

The SAFE study found a significant improvement in skills and confidence after the initial high-fidelity simulation training that were retained after 6 months.

Impact of a virtual reality-based simulation training for shoulder dystocia on human and technical skills among caregivers: a randomized-controlled trial

This study analyzed the adherence to the modified Advanced Life Support in Obstetrics (ALSO) algorithm (HELP-RER) for handling shoulder dystocia (SD) using a virtual reality (VR) training modality. Secondary outcomes were improvements in the post-training diagnosis-to-delivery time, human skills factors (HuFSHI), and perceived task-load index (TLX). Prospective, case-control, single-blind, 1:1 randomized crossover study. Participants were shown a 360° VR video of SD management. The control group was briefed theoretically. Both groups underwent HuFSHI and HELP-RER score assessments at baseline and after the manikin-based training. The TLX questionnaire was then administered. After a washout phase of 12 weeks, we performed a crossover, and groups were switched. There were similar outcomes between groups during the first training session. However, after crossover, the control group yielded significantly higher HELP-RER scores [7 vs. 6.5; (p = 0.01)], with lower diagnosis-to-delivery-time [85.5 vs. 99 s; (p = 0.02)], and TLX scores [57 vs. 68; (p = 0.04)]. In the multivariable linear regression analysis, VR training was independently associated with improved HELP-RER scores (p = 0.003). The HuFSHI scores were comparable between groups. Our data demonstrated the feasibility of a VR simulation training of SD management for caregivers. Considering the drawbacks of common high-fidelity trainings, VR-based simulations offer new perspectives.

Perceived self-efficacy to teach comprehensive abortion care among nursing and midwifery faculty in higher learning institutions in Rwanda: A mixed method study

INTRODUCTION

Comprehensive abortion care is an emerging intervention being integrated into nursing and midwifery curricula. Yet, no studies have been conducted in Rwanda to determine whether faculty perceive themselves as capable of teaching comprehensive abortion care. This study aims to evaluate the perceived self-efficacy to teach comprehensive abortion care among nursing and midwifery faculty in higher learning institutions in Rwanda.

MATERIALS AND METHODS

The University of Rwanda College of Medicine and Health Sciences Institutional Review Board approved this study (UR-CMHS-IRB No 335/CMHSIRB/2022). In quantitative, a self-administered questionnaire was administered to 98 study participants. Data were entered into Statistical Package for the Social Sciences (SPSS) version 26 and analyzed using Chi-square test with a p-value of 0.05 set as the significance level. In the qualitative part, an interview guide was developed based on quantitative data to understand comprehensive abortion care teaching fully. Data were collected from four focus group discussions with eight participants in each group, entered in Dedoose, and analyzed thematically.

RESULTS

Among the 98 study participants who were invited to participate in this study, only 85 filled out the questionnaires. This translates into 86.7% of the response rate. More than half 58.8% had adequate self-efficacy in teaching comprehensive abortion care. A Chi-square test has revealed that being a male, being a midwife, and having more years of working experience in nursing education were significantly associated with self-efficacy in teaching comprehensive abortion care (p value <0.05). In the qualitative phase, 32 study participants participated in four focus group discussions and four themes were identified: a) variability in confidence levels to teach comprehensive abortion care; b) readiness about teaching comprehensive abortion care; c) facilitators of teaching comprehensive abortion care; and d) contextual challenges to teach comprehensive abortion care.

CONCLUSIONS

The findings revealed that faculty's self-efficacy in teaching comprehensive abortion care was not adequate. Personal and religious beliefs and institutional barriers were also reported to hinder self-efficacy in teaching comprehensive abortion care. Therefore, intensive comprehensive abortion care training for nursing and midwifery faculty in higher learning institutions should be provided, including values clarification and attitude transformation training for attitudes and beliefs. It is also critical for higher learning institutions to develop strategies for overcoming the challenges faculty face when teaching comprehensive abortion care.

Maternal and neonatal complications of shoulder dystocia with a focus on obstetric maneuvers: A case-control study of 1103 deliveries

INTRODUCTION

Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates.

MATERIAL AND METHODS

The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD-10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD-10 codes were also scrutinized.

RESULTS

Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third- or fourth-degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24).

CONCLUSIONS

The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines.

Powerful medical education improves health care quality and return on investment

INTRODUCTION

Powerful medical education (PME) involves the use of new technologies informed by the science of expertise that are embedded in laboratories and organizations that value evidence-based education and support innovation. This contrasts with traditional medical education that relies on a dated apprenticeship model that yields uneven results. PME involves an amalgam of features, conditions and assumptions, and contextual variables that comprise an approach to developing clinical competence grounded in education impact metrics including efficiency and cost-effectiveness.

METHODS

This article is a narrative review based on SANRA criteria and informed by realist review principles. The review addresses the PME model with an emphasis on mastery learning and deliberate practice principles drawn from the new science of expertise. Pub Med, Scopus, and Web of Science search terms include medical education, the science of expertise, mastery learning, translational outcomes, cost effectiveness, and return on investment. Literature coverage is comprehensive with selective citations.

RESULTS

PME is described as an integrated set of twelve features embedded in a group of seven conditions and assumptions and four context variables. PME is illustrated via case examples that demonstrate improved ventilator patient management learning outcomes compared to traditional clinical education and mastery learning of breaking bad news communication skills. Evidence also shows that PME of physicians and other health care providers can have translational, downstream effects on patient care practices, patient outcomes, and return on investment. Several translational health care quality improvements that derive from PME include reduced infections; better communication among physicians, patients, and families; exceptional birth outcomes; more effective patient education; and return on investment.

CONCLUSIONS

The article concludes with challenges to hospitals, health systems, and medical education organizations that are responsible for producing physicians who are expected to deliver safe, effective, and cost-conscious health care.

Low-Cost Ear Procedure Simulator With Syringe and Tuning Fork: Training Course and Results

INTRODUCTION

Medical simulation is a continuously expanding field. In surgical specialties, in particular, simulation can provide an alternative avenue for learning. The objective of this process improvement project was to evaluate the effectiveness and practicality of adding simulation-based training to our educational curriculum regarding common otologic procedures.

MATERIALS AND METHODS

A low-cost, novel ear procedure simulator was designed and constructed from readily available clinic supplies. Participants were asked to fill out a pre-simulator survey to assess their own comfort and skill level before undergoing the simulation course. A pre-simulation PowerPoint training course was then administered to participants. The participants then underwent the simulation training course and were again asked to fill out a post-simulator training exercise survey to reassess their own comfort and skill level. Institutional review board approval was not required by Tripler Army Medical Center.

RESULTS

A total of 15 participants consisting of junior residents in otolaryngology, third- and fourth-year medical students rotating on an otolaryngology clinical clerkship, and one physician assistant in otolaryngology were included in the study. There was a significant improvement in both provider comfort with the procedure and clinical performance of the procedure among participants after training on the simulation-based model.

CONCLUSIONS

Simulation-based training provides a safe, effective, and cost-friendly alternative to clinical medical education. Future studies are needed to address the wide-scale applicability of these results to other forms of surgical training.

Comparison of practice vs theory model training for vacuum-assisted delivery: A randomized controlled trial

OBJECTIVE

To assess the effect of two modalities of simulation training on acquisition/retention of skills for performing operative vaginal delivery.

DESIGN

Randomized, controlled, single-centre study.

SETTING

A tertiary referral hospital in Italy.

PARTICIPANTS

Twenty residents from a single university programme and two young specialists.

INTERVENTION

Group 1 had an individual training session with a single senior specialist using a fixed simulator model. After the session, trainees watched a pre-recorded 1-h lecture on vacuum-assisted operative vaginal delivery. Group 1 repeated the simulator session using the same test after 8-12 weeks and 12 months. Group 2 watched the pre-recorded lecture then undertook the same sessions as Group 1. Video recordings of all test performances were evaluated by five specialists in a blinded manner.

MAIN OUTCOME MEASURE

Each procedure was evaluated using a Global Rating Scale (GRS), scored with 0-5 points for each item on an Objective Structured Assessment of Technical Skills (OSATS) dataset with seven items (total 35 points). OSATS were evaluated over time, compared for the whole population, and weighted for route and year of residency. The primary outcome was comparison of the effectiveness of training between the two groups based on year of residency by assessing videos of the baseline test and GRS for OSATS scores. The secondary outcome was overall retention of skills at 8-12 weeks and 12 months.

RESULTS

Twenty-two participants were recruited and randomized to either Group 1 (n = 11) or Group 2 (n = 11). Five participants did not complete follow-up. The primary outcome of GRS for OSATS scores at time 0 differed significantly between groups for total GRS score, and 'Call for help' and 'Explanation to woman and relatives' item scores (p = 0.002 and p = 0.007, respectively). In a multiple linear regression analysis, OSATS scores were not independently influenced by year of residency. At 8-12-week follow-up, the 'Call for help' item score showed a significant improvement in Group 1 (p = 0.018), although this was not confirmed when year of residency was included as an independent variable. At 12-month follow-up, none of the item scores demonstrated a significant change (p = 0.033). Year of residency did not influence the difference between groups. One-way analysis of variance found significant differences between the groups for 'Localization of the flexion point' (p = 0.005), 'Traction of vacuum cup' (p = 0.039) and 'Use of second hand of the operator' (p = 0.009) item scores and total GRS score (p = 0.007). The values weighted by year of residency did not demonstrate any significant difference. The secondary outcomes evaluated all the candidates of both groups for retention of technical skills over time. A significant effect of time was found for total GRS score (p < 0.001) and OSATS item scores.

CONCLUSIONS

Independent of the sequence of theoretical teaching and simulation training, trainees demonstrated high retention - and, actually, improvement - of technical skills for operative vaginal delivery at 12-month follow-up.

Necessity of Pretests in Central Venous Catheter Insertion Simulation-Based Mastery Learning: A Randomized Controlled Trial

PURPOSE

Simulation-based mastery learning (SBML) is a rigorous form of competency-based learning. Components of SBML include a pretest, deliberate practice, and a posttest; all learners must meet or exceed a minimum passing standard (MPS) on the posttest before completing training. The authors aimed to explore whether a modified SBML curriculum (without a pretest assessment) was as effective as the standard SBML curriculum (with a pretest assessment).

METHOD

The authors performed a randomized controlled trial of internal medicine residents who participated in an internal jugular central venous catheter insertion SBML curriculum at a tertiary care academic medical center in Chicago, Illinois, from December 2018 through December 2021. Residents were randomly assigned to complete the usual SBML intervention (pretest group) or to complete a modified SBML intervention without a pretest (no pretest group). The authors compared initial posttest performance and training time between groups.

RESULTS

Eighty-nine of 120 eligible residents (74.1%) completed the study: 43 in the pretest group and 46 in the no pretest group. Median (IQR) initial posttest scores were not statistically different between the pretest group (96.6 [93.1-100]) and the no pretest group (96.6 [92.4-100]). However, all 43 residents (100%) in the pretest group reached the MPS at the initial posttest compared with 41 of the 46 (89%) in the no pretest group ( P = .06). Residents in the pretest group required 16.5 hours more faculty and learning time than the no pretest group.

CONCLUSIONS

More residents who completed a pretest reached the MPS at initial posttest. However, incorporating a pretest during the internal jugular central venous catheter SBML curriculum required substantially more learner and faculty time without clear performance benefits.

Simulation to improve trainee knowledge and comfort in managing maternal cardiac arrest

BACKGROUND

Maternal cardiac arrest is a rare outcome, and thus there are limited opportunities for specialists in obstetrics and gynecology to acquire the skills required to respond to it through routine clinical practice.

OBJECTIVE

This study aimed to evaluate gaps in medical education in maternal cardiac arrest and whether a simulation-based training program improves resident knowledge and comfort in the diagnosis and treatment of maternal cardiac arrest.

STUDY DESIGN

A 2-hour training for obstetrics and gynecology residents at an academic medical center was conducted, consisting of a didactic presentation, defibrillator skills station, and 2 high-fidelity simulations. Consenting residents completed a 21-item pretest followed by a 12-item posttest exploring knowledge of and exposure to maternal cardiac arrest. The McNemar and Wilcoxon signed-rank tests were used to compare pre- and posttest data.

RESULTS

Of 21 residents, 15 (71.4%) had no previous education about maternal cardiac arrest, and 17 (81.0%) had never responded to a maternal code. Participants demonstrated increased knowledge about maternal cardiac arrest after the session, providing more correct answers on the reversible causes of pulseless electrical activity arrest (median 4 vs 7 correct responses; P<.01). After the training, more residents were able to identify the correct gestational age to perform a cesarean delivery during maternal cardiac arrest (19.0% vs 90.5%; P<.01) and the correct location for this procedure (52.4% vs 95.2%; P<.01). All residents reported that maternal cardiac arrest training was important and that they would benefit from additional sessions. Median composite comfort level in managing maternal cardiac arrest significantly increased after participation (pretest, 24.0 [interquartile range, 21.5-28.0]; posttest, 37.0 [interquartile range, 34.3-41.3]; P<.01).

CONCLUSION

Residents report limited exposure to maternal cardiac arrest and desire more training. Simulation-based training about maternal cardiac arrest is needed during residency to ensure that graduates are prepared to respond to this high-acuity event.

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

OBJECTIVE

To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.

TARGET POPULATION

Providers working to improve health care for Canadian women and their families; patients and their families.

OUTCOMES

Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.

BENEFITS, HARMS, AND COSTS

This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.

EVIDENCE

Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.

RECOMMENDATIONS

Simulation-based training in obstetric anesthesia: an update

In this update we explore the current applications of simulation in obstetric anesthesia, describe what is known regarding its impacts on care and consider the different settings in which simulation programs are required. We will introduce practical strategies, such as cognitive aids and communication tools, that can be applied in the obstetric setting and share ways in which a program might apply these tools. Finally, we provide a list of common obstetric emergencies essential for a program's curriculum and common teamwork pitfalls to address within a comprehensive obstetric anesthesia simulation program.

Incidence of obstetric brachial plexus palsy after a training program in shoulder dystocia

INTRODUCTION

Shoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to determine the incidence of obstetric brachial plexus palsy and other neonatal complications associated with shoulder dystocia in deliveries managed in a university hospital after the implementation of a simulation-based training that was offered to all the labour and delivery staff on a voluntary basis.

MATERIAL AND METHODS

Retrospective observational study including all cases of shoulder dystocia and associated complications (mainly obstetric brachial plexus palsy) documented between January 2017 and December 2020, after the implementation of the training. In addition, we collected retrospective data on cases of obstetric brachial plexus palsy that developed in the hospital before the training (2008-2016).

RESULTS

In the 2017-2020 period, in the total of 125 cases of shoulder dystocia (amounting to 1.38% of vaginal deliveries), there were 14 cases of obstetric brachial plexus palsy (11.2% of the cases of shoulder dystocia), 7 clavicle fractures and 1 humerus fracture; none of the cases of obstetric brachial plexus palsy was permanent or required treatment or rehabilitation past six months. In the years preceding the training, there were 7 cases of obstetric brachial plexus palsy, 2 permanent and 5 temporary (3 of which required rehabilitation).

CONCLUSION

These results reflect the importance of knowing the morbidity present in the labour and delivery ward and the potential benefit of simulation-based training programmes in the resolution of these obstetric complications.

Getting Ready for 2021 Joint Commission Perinatal Standards: Lessons From the Field

SUMMARY STATEMENT

The new Joint Commission requirements on perinatal safety present a unique opportunity for the simulation community to actively engage with labor and delivery units nationwide. Considerations for implementation using "real-life" experience with the programmatic development of an in situ team-based simulation training program in obstetric emergencies are discussed. We urge simulationists to explore opportunities to promote culture change on a large scale to move the needle of maternal morbidity and mortality.

Guidelines for the management of urgent obstetric situations in emergency medicine, 2022

OBJECTIVE

To provide recommendations on the management of urgent obstetrical emergencies outside the maternity ward.

DESIGN

A group of 24 experts from the French Society of Emergency Medicine (SFMU), the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French College of Gynaecologists and Obstetricians (CNGOF) was convened. Potential conflicts of interest were formally declared at the outset of the guideline development process, which was conducted independently of industry funding. The authors followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the level of evidence in the literature. The potential drawbacks of strong recommendations in the presence of low-level evidence were highlighted. Some recommendations with an insufficient level of evidence were not graded.

METHODS

Eight areas were defined: imminent delivery, postpartum haemorrhage (prevention and management), threat of premature delivery, hypertensive disorders in pregnancy, trauma, imaging, cardiopulmonary arrest, and emergency obstetric training. For each field, the expert panel formulated questions according to the PICO model (population, intervention, comparison, outcomes) and an extensive literature search was conducted. Analysis of the literature and formulation of recommendations were conducted according to the GRADE method.

RESULTS

Fifteen recommendations on the management of obstetrical emergencies were issued by the SFMU/SFAR/CNGOF panel of experts, and 4 recommendations from formalised expert recommendations (RFE) established by the same societies were taken up to answer 4 PICO questions dealing with the pre-hospital context. After two rounds of voting and several amendments, strong agreement was reached for all the recommendations. For two questions (cardiopulmonary arrest and inter-hospital transfer), no recommendation could be made.

CONCLUSIONS

There was significant agreement among the experts on strong recommendations to improve practice in the management of urgent obstetric complications in emergency medicine.

Simulation in Obstetric Emergencies

Simulation is a critical part of training for obstetric emergencies. Incorporation of this training modality has been shown to improve outcomes for patients and is now required by national accrediting organizations.

Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: an observational study

OBJECTIVE

To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI).

DESIGN

Retrospective observational study.

SETTING

Helsinki University Women's Hospital, Finland.

SAMPLE

Deliveries with SD.

METHODS

Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed.

RESULTS

During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm.

CONCLUSIONS

Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI.

Correlation between medical management and teamwork in multidisciplinary high-fidelity obstetrics simulations

BACKGROUND

Teamwork and communication gaps are consistently cited as contributors to adverse outcomes in obstetrics. The Critical Care in Obstetrics Course provides an innovative experience by combining brief interactive didactics with the opportunity to practice and implement the knowledge gained with hands-on simulation. Most participants have never worked together, which creates a unique environment to evaluate the importance of teamwork and communication.

OBJECTIVE

This study aimed to evaluate the association between teamwork and medical management in high-fidelity critical care simulations.

STUDY DESIGN

The participants were separated into multidisciplinary teams and taken through simulations, including placental abruption, hypertensive emergency, eclampsia, sepsis, cardiac arrest, venous thromboembolism, diabetic ketoacidosis, and thyroid storm. Facilitators completed a validated checklist assessment for each group's performance in medical care and teamwork. Each element was rated on a scale from 1 to 5, with 1 being unacceptable and 5 being perfect. We evaluated 5 communication measures, including the use of closed-loop communication and orientation of new team members. A Spearman correlation was used to evaluate the relationship between total medical management and total teamwork scores and specific measures of team communication. Receiver operating characteristic curves were created for total teamwork score as a predictor of good or perfect medical management.

RESULTS

A total of 354 multidisciplinary teams participated in 1564 high-fidelity simulations. There was a significant correlation between medical management and teamwork and communication scores for all scenarios. The strongest correlation was for the total teamwork score for all simulations (ρ=0.84). Teamwork scores were highly predictive of medical management scores with an area under the curve of at least 0.88 for all simulations, although this was not significant for diabetic ketoacidosis.

CONCLUSION

The quality of teamwork and communication correlated with the quality of clinical performance in newly formed multidisciplinary teams. This demonstrates the importance of teamwork training, with a focus on key communication tools and strategies, among medical providers to optimize the management of complex and emergent obstetrical conditions.

Optical ultrasound simulation-based training in obstetric sonography

Ultrasound is an imaging modality that is highly operator dependent. This article reviews the challenges in learning how to perform obstetric sonography, as well as the processes necessary to acquire expert performance skills in sonography. Simulation-based education and learning, and the value of medical simulation are also discussed. Ultrasound simulators are an effective means of teaching obstetric sonography, because it provides training, deliberate practice, and performance evaluation/feedback which allows continuous and critical self-evaluation. We review evidence that simulation can improve performance in obstetric ultrasound examination, review current simulators, and discuss the current problems/gaps in ultrasound simulation. Optical positioning ultrasound simulation is a novel high-fidelity simulation learning system, which addresses many of these problems/gaps and is introduced for the first time here.

A push for evidence: An effective training in operative birth

Effective training in operative birth should be the only type of operative birth that trains the junior obstetricians who are exposed to it. Although it remains difficult to fully characterise, effective training in operative birth is likely to include (i) realistic, local, integrated simulation training and (ii) hands-on senior support for an extended period of time. To further improve skills training in operative birth, an evaluation of the real-world effectiveness of current training should take place, a core outcome set for clinical trials should be developed, and real-time reporting and tracking of practitioner-specific outcome measures should be implemented.

Simulation in Obstetrics and Gynecology: A Review of the Past, Present, and Future

Simulation in obstetrics and gynecology has advanced significantly since its beginnings in the seventeenth century with wooden birthing and pelvic models. In recent years, more and more evidence has emerged showing improvements in participant confidence, skills, behaviors, and, finally, patient outcomes following simulation program implementation. Several regulatory bodies and national organizations have begun to require simulation of obstetrician-gynecologists, and the newer generation of physicians has experienced simulation throughout their training. Simulation is embedded in the medical culture and hopefully is making obstetrician-gynecologists better for it.

Does simulation improve clinical performance in management of postpartum hemorrhage?

BACKGROUND

Although simulation is now widely used to improve teamwork and communication, data demonstrating improvement in clinical outcomes are limited.

OBJECTIVE

This study aimed to examine the clinical performance and outcomes associated with postpartum hemorrhage because of uterine atony following the implementation of a multidisciplinary simulation program.

STUDY DESIGN

This was a prospective observational study of response to postpartum hemorrhage because of uterine atony in an academic medical center before (epoch 1: July 2017-June 2018) and after (epoch 2: July 2019-June 2020) implementing a multidisciplinary simulation program. A total of 22 postpartum hemorrhage simulations were performed from July 2018 to June 2019 involving more than 300 nursing, obstetrical, and anesthesia providers. The simulation program focused on managing postpartum hemorrhage events and improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of the simulation program, the primary outcome was response to postpartum hemorrhage defined as the time from the administration of uterotonic medications to transfusion of the first unit of blood in the first 12 hours following delivery, comparing epoch 2 to epoch 1 following the implementation of a simulation program. Statistical analysis included the use of the Pearson chi-square test, Wilcoxon rank-sum test, Hodges-Lehmann statistic for differences, and bootstrap methods with a P value of <.05 considered significant.

RESULTS

Between July 1, 2017, and June 30, 2018, there were 12,305 patients who delivered, of which 495 patients (4%) required transfusion. Between July 1, 2019, and June 30, 2020, there were 12,414 patients who delivered, of which 480 patients (4%) required transfusion. When isolating cases of postpartum hemorrhage because of uterine atony in both transfused groups, there were 157 women in the presimulation group (epoch 1) and 165 women in the postsimulation group (epoch 2), respectively. There was no difference in age, race, parity, or perinatal outcomes between the 2 epochs. Women in epoch 2 began receiving blood products significantly earlier in the first 12 hours following delivery compared with women in epoch 1 (51 [range, 28-125] minutes vs 102 [range, 32-320] minutes; P=.005). In addition, there was a significantly decreased variation in the time from the administration of uterotonic medications to transfusion of blood in epoch 2 (P=.035). Furthermore, women in epoch 2 had significantly lower estimated blood loss than women in epoch 1 (1250 [range, 1000-1750] mL vs 1500 [range, 1000-2000] mL; P=.032).

CONCLUSION

The implementation of a multidisciplinary simulation program at a large academic center focusing on the management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from the administration of uterotonic medications to transfusion of blood, decreased variance in the time from the administration of uterotonic medications to transfusion of blood, and lower estimated blood loss following the implementation of a simulation program. Because delay in treatment is a major cause of preventable maternal death in obstetrical hemorrhage, the results in our study provided clinical evidence that a simulation program may improve patient outcomes in such emergencies.

PROMPT Wales project: national scaling of an evidence-based intervention to improve safety and training in maternity

BACKGROUND

In healthcare, there is increasing recognition of the importance of developing and testing strategies to scale effective interventions. The NHS long-term plan (2019) acknowledges that often a gold standard approach to a problem already exists somewhere within the NHS, however, it has not been replicated widely across the system.

METHODS

We describe the approach and process measures for national scaling of PROMPT (Practical Obstetric Multi-Professional Training) across 12 obstetric-led maternity units in Wales. PROMPT is an evidence-based training package for local maternity staff, previously associated with improvements in maternal and neonatal outcomes, reduction in litigation related to preventable harm and improved safety culture. PROMPT has previously been disseminated internationally using a train-the-trainer model. However, this has been associated with variations in uptake, fidelity and impact. In Wales, the project was supported by Welsh Government, and a structured scaling plan was developed, encompassing ongoing implementation support from a multi-professional team.

RESULTS

PROMPT was successfully implemented in all obstetric led units in Wales, with 326 local PROMPT facilitators trained, and 82.5%-100% of maternity staff attended a local PROMPT course in the first 15 months of the project (January 2019-March 2020). All training courses included evidence-based authentic elements, and 93% of courses in the first year (100/107) were supported by a national implementation team, providing coaching, implementation support and quality assurance.

CONCLUSIONS

Authentically scaling up complex interventions is a significant challenge. To replicate the improved outcomes demonstrated by PROMPT, intervention reach and fidelity must first be demonstrated.In this national scaling project, our scaling methodology led to the successful implementation of PROMPT across all health boards in Wales. Additionally, we demonstrated reduced variation in adoption, reach, timescale and intervention fidelity between maternity units with varying readiness for change, which had been difficult in two previous large-scale PROMPT implementation projects.

Comparison of a practice-based versus theory-based training program for conducting vacuum-assisted deliveries: a randomized-controlled trial

PURPOSE

Vacuum-assisted deliveries (VAD) are complex procedures that require training and experience to be performed proficiently. We aimed to evaluate if a more resource intensive practice-based training program for conducting VAD is more efficient compared to a purely theory-based training program, with respect to immediate training effects and persistence of skills 4-8 weeks after the initial training.

METHODS

In this randomized-controlled study conducted in maternity staff, participants performed a simulated low-cavity non-rotational vacuum delivery before (baseline test) and immediately after the training (first post-training test) as well as 4-8 weeks thereafter (second post-training test). The study's primary endpoint was to compare training effectiveness between the two study groups using a validated objective structured assessment of technical skills (OSATS) rating scale.

RESULTS

Sixty-two participants were randomized to either the theory-based group (n = 31) or the practice-based group (n = 31). Total global and specific OSATS scores, as well as distance of cup application to the flexion point improved significantly from baseline test to the first post-training test in both groups (p_all < 0.007). Skill deterioration after 4-8 weeks was only found in the theory-based group, whereas skills remained stable in the practice-based group.

CONCLUSION

A practice-based training program for conducting VAD results in comparable immediate improvement of skills compared to a theory-based training program, but the retention of skills 4-8 weeks after training is superior in a practice-based program. Future studies need to evaluate, whether VAD simulation training improves maternal and neonatal outcome after VAD.

Cesarean rate in selected hospital network of private sector: A retrospective study

INTRODUCTION

In Spain over the last two decades, cesarean section (CS) rates have increased from 15 to 25% in the Public Health Sector and from 28 to 38% in the private sector. There are multiples causes for this rise, which are often unclear. The aim of our study is to collect and analyze all the CS rates data from a hospital network of the 42 Quirónsalud Hospitals (private sector) and to assess its distribution regarding the different types of hospitals and patient characteristics.

MATERIAL AND METHODS

An observational retrospective study between 2017 and 2018 was performed. Hospitals are classified into three groups: large hospitals (11), medium hospitals (17) and small hospitals (14). The cesarean section rate was measured by patient categorization into three groups: total deliveries, low risk cesarean sections and low risk cesarean sections without previous cesarean delivery.

RESULTS

We analyzed 62,685 deliveries: 42,987 were vaginal deliveries (68.6%) and 19,698 CS (31.4%). The mean age for the total number of deliveries was 34.18 years old, whilst the mean age for the low-risk group was 34.12. Of the 19,698 CS, 18.36% (3618) were in high-risk population and 81.63% (16,080) in low risk population. 69.54% (11,183) of the low-risk CS were in patients without a previous CS.

CONCLUSIONS

The overall rate of CS in the Quirónsalud group is slightly higher than the one from the Public Healthcare. The older maternal age as well as the hospital resources involved in the delivery attendance can explain this difference.

Impact of a simulation-based training on the experience of the beginning of residency

INTRODUCTION

We aimed to evaluate the impact of an immersive simulation session on the experience of the beginning of residency.

METHODS

The interventional group consisted of newly recruited residents in 2019, who participated in the workshop presenting four emergency scenarios frequently encountered during night shifts; the control group comprised residents who had begun their internship in 2018, without having participated in the simulation workshop. The level of psychological stress and self-confidence were self-estimated in the simulation group before and immediately after the workshop. During the second semester of residency, stress, self-efficacy and anxiety were evaluated in both groups with the Perceived Stress Scale (PSS), General Self-efficacy Scale (GSES), and Generalized Anxiety Disorder-7 (GAD-7) scale.

RESULTS

In the second semester 2020, the PSS, GSES and GAD-7 were 20.71±8.15 and 22.44±5.68 (P=0.40); 26.88±6.30 and 27.11±3.95 (P=0.87); 6.94±5.25 and 8.89±4.78 (P=0.22) for the simulation (n=17, 89.5% of participation) and control (n=9, 75%) groups, respectively. In the simulation group, the level of self-confidence had significantly improved from 1.82±0.95 before the session to 2.29±1.16 after the session (P=0.05). Interestingly, this improvement in self-confidence was significantly correlated with GAD-7 (P=0.014) and PSS (P=0.05), and tended to be correlated with GSES (P=0.09).

CONCLUSION

Our study showed a significant improvement in self-confidence between before and after the simulation session. Residents who experienced an improvement in self-confidence saw their stress and anxiety levels decrease during the second semester reevaluation, in favor of a prolonged benefit from the session.

Exploration of simulation-based medical education for undergraduate students

Over the past decades, extensive studies have underscored the growing importance of simulation-based medical education (SBME) for medical students. However, the underlying influence of SBME on undergraduate students is yet to be investigated. This work is a single-center cohort study involving 1178 undergraduate students who were divided into a control group and an SBME group. All participants gave their written informed consent. We compared the theoretical and practical achievements of these 2 groups and distributed a feedback questionnaire. Results show that SBME significantly improves the practical or theoretical achievements of students (P < .001). The humanistic care (improvement rate: 69.2%) and doctor-patient communication (improvement rate: 56.3%) performances of these studies were vastly improved. The students in the SBME group tend to allocate more time to communicating with others. SBME is an effective teaching method that can improve the reflective capacity and communication skills of undergraduate medical students, thereby resulting in their relatively improved performance.

Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation

Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

Shoulder dystocia, umbilical cord blood gases and neonatal encephalopathy

The interpretation of umbilical cord gases may not be straightforward following shoulder dystocia. We reviewed Perinatal and Maternal Mortality Review Committee data from New Zealand infants with moderate and severe neonatal encephalopathy (NE) for 2010-2017 inclusive. If one or more of: pH of ≤7.1; base excess of ≤-12 mmol/L; or lactate of ≥6 mmol/L were present it was considered an abnormal result. One-third (12/36) of infants born following shoulder dystocia had documented umbilical cord gases within the normal range. It is important for clinicians to be aware of this possibility when assessing newborn infants with NE.

Shoulder dystocia and composite adverse outcomes for the maternal-neonatal dyad

BACKGROUND

Although the neonatal morbidity associated with shoulder dystocia are well known, the maternal morbidity caused by this obstetrical emergency is infrequently reported.

OBJECTIVE

This study aimed to assess the composite adverse maternal and neonatal outcomes among vaginal deliveries (at 34 weeks or later) with and without shoulder dystocia.

STUDY DESIGN

This is a secondary analysis of the Consortium of Safe Labor, an observational obstetrical cohort of all vaginal deliveries occurring at 19 hospitals (from 2002-2008) and for which data on the occurrence of shoulder dystocia were available. The composite adverse maternal outcome included third- or fourth-degree perineal laceration, postpartum hemorrhage (>500 cc blood loss for a vaginal delivery and >1000 cc blood loss for cesarean delivery), blood transfusion, chorioamnionitis, endometritis, thromboembolism, admission to intensive care unit, or maternal death. The composite adverse neonatal outcome included an Apgar score of <7 at 5 minutes, a birth injury, neonatal seizure, hypoxic ischemic encephalopathy, or neonatal death. A multivariable Poisson regression was used to estimate the adjusted relative risks with 95% confidence intervals. The area under the receiver operating characteristic curve was constructed to determine if clinical factors would identify shoulder dystocia.

RESULTS

Of the 228,438 women in the overall cohort, 130,008 (59.6%) met the inclusion criteria, and among them, shoulder dystocia was documented in 2159 (1.7%) cases. The rate of composite maternal morbidity was significantly higher among deliveries with shoulder dystocia (14.7%) than without (8.6%; adjusted relative risk, 1.71; 95% confidence interval, 1.64-2.01). The most common maternal morbidity with shoulder dystocia was a third- or fourth-degree laceration (adjusted relative risk, 2.82; 95% confidence interval, 2.39-3.31). The risk of composite neonatal morbidity with shoulder dystocia (12.2%) was also significantly higher than without shoulder dystocia (2.4%) (adjusted relative risk, 5.18; 95% confidence interval, 4.60-5.84). The most common neonatal morbidity was birth injury (adjusted relative risk, 5.39; 95% confidence interval, 4.71-6.17). The area under the curve for maternal characteristics to identify shoulder dystocia was 0.66 and it was 0.67 for intrapartum factors.

CONCLUSION

Although shoulder dystocia is unpredictable, the associated morbidity affects both mothers and newborns. The focus should be on concurrently averting the composite morbidity for the maternal-neonatal dyad with shoulder dystocia.

TeamSTEPPS online simulation: expanding access to teamwork training for medical students

Background

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) programme is an evidence-based approach to teamwork training. In-person education is not always feasible for medical student education. The aim of this study was to evaluate the impact of online, interactive TeamSTEPPS simulation versus an in-person simulation on medical students’ TeamSTEPPS knowledge and attitudes.

Methods

Fourth-year medical students self-selected into an in-person or online training designed to teach and evaluate teamwork skills. In-person participants received didactic sessions, team-based medical simulations and facilitated debriefing sessions. The online group received an equivalent online didactic session and participated in an interactive software-based simulation with immediate, personalised performance-based feedback and scripted debriefing. Both trainings used three iterations of a case of septic shock, each with increasing medical complexity. Participants completed a demographic survey, a preintervention/postintervention TeamSTEPPS Benchmarks test and a retrospective preintervention/postintervention TeamSTEPPS teamwork attitudes questionnaire. Data were analysed using descriptive statistics and repeated measures analysis of variance.

Results

Thirty-one students (18 in-person, 13 online) completed preintervention/postintervention surveys, tests and questionnaires. Gender, age and exposure to interprofessional education, teamwork training and games were similar between groups. There were no statistical differences in preintervention knowledge or teamwork attitude scores between in-person and online groups. Postintervention knowledge scores increased significantly from baseline (+2.0% p=0.047), and these gains did not differ significantly based on whether participants received in-person versus online training (+1.5% vs +2.9%; p=0.49). Teamwork attitudes scores also showed a statistically significant increase with training (+0.9, p<0.01) with no difference in the effect of training by group (+0.8 vs +1.0; p=0.64).

Conclusions

Graduating medical students who received in-person and online teamwork training showed similar increases in TeamSTEPPS knowledge and attitudes. Online simulations may be used to teach and reinforce team communication skills when in-person, interprofessional simulations are not feasible.

Simulation-based curriculum development: lessons learnt in Global Health education

BACKGROUND

Simulation based medical education (SBME) allows learners to acquire clinical skills without exposing patients to unnecessary risk. This is especially applicable to Emergency Medicine training programs where residents are expected to demonstrate proficiency in the management of time critical, low frequency, and highly-morbidity conditions. This study aims to describe the process through which a SBME curriculum was created, in a limited simulation resource setting at a 4-year Emergency Medicine (EM) residency program at the American University of Beirut Medical Center.

METHODS

A case-based pilot simulation curriculum was developed following Kern's 6 step approach to curriculum design. The curricular objectives were identified through an anonymous survey of the program's residents and faculty. Curriculum outcomes were assessed, and the curriculum was revised to address curricular barriers. Evaluations of the revised curriculum were collected during the simulation sessions and through a whole revised curriculum evaluation at the end of the first year of its implementation.

RESULTS

14/20 residents (70%) and 8/8 faculty (100%) completed the needs assessment from which objectives for the pilot curriculum were developed and implemented through 6 2-h sessions over a 1-year period. Objectives were not met and identified barriers included cost, scheduling, resources, and limited faculty time. The revised curriculum addressed these barriers and 24 40-min sessions were successfully conducted during the following year. The sessions took place 3 at a time, in 2-h slots, using the same scenario to meet the objectives of the different learners' levels. 91/91 evaluations were collected from participants with overall positive results. The main differences between the pilot and the revised curricula included: a better understanding of the simulation center resources and faculty's capabilities.

CONCLUSION

Simulation-based education is feasible even with limited-resources. However, understanding the resources available, and advocating for protected educator time are essential to implementing a successful EM simulation curriculum.

Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance

BACKGROUND

Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care.

OBJECTIVES

To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience.

SEARCH METHODS

The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes.

MAIN RESULTS

We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries. Kirkpatrick level 4 (patient outcome) Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence) Kirkpatrick level 3 (performance in practice) We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions).

AUTHORS' CONCLUSIONS

Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.

Simulation for intrapartum care: from training to novel device innovation

Improving maternal and perinatal care is a global priority. Simulation training and novel applications of simulation for intrapartum care may help to reduce preventable deaths worldwide. Evaluation studies have published details of the effectiveness of simulation training for obstetric emergencies, exploring clinical and non-clinical factors as well as the impact on patient outcomes (both maternal and neonatal). This review summarized the many uses of simulation in obstetric emergencies from training to assessment. It also described the adaption of training in low-resource settings and the evidence behind the equipment recommended to support simulation training. The review also discussed novel applications for simulation such as its use in the development of a new device for assisted vaginal birth and its potential role in Cesarean section training. This study analyzed the financial implications of simulation training and how this may impact the delivery of such training packages, considering that simulation should be developed and utilized as a key tool in the development of safe intrapartum care in both emergency and non-emergency settings, in innovation and product development.

Simulation-Based Team Leadership Training Improves Team Leadership During Actual Trauma Resuscitations: A Randomized Controlled Trial

OBJECTIVES

Trauma resuscitations are complex critical care events that present patient safety-related risk. Simulation-based leadership training is thought to improve trauma care; however, there is no robust evidence supporting the impact of leadership training on clinical performance. The objective of this study was to assess the clinical impact of simulation-based leadership training on team leadership and patient care during actual trauma resuscitations.

DESIGN

Randomized controlled trial.

SETTING

Harborview Medical Center (level 1 trauma center).

SUBJECTS

Seventy-nine second- and third-year residents were randomized and 360 resuscitations were analyzed.

INTERVENTIONS

Subjects were randomized to a 4-hour simulation-based leadership training (intervention) or standard orientation (control) condition.

MEASUREMENTS AND MAIN RESULTS

Participant-led actual trauma resuscitations were video recorded and coded for leadership behaviors and patient care. We used random coefficient modeling to account for the nesting effect of multiple observations within residents and to test for post-training group differences in leadership behaviors while controlling for pre-training behaviors, Injury Severity Score, postgraduate training year, and days since training occurred. Sixty participants completed the study. There was a significant difference in post-training leadership behaviors between the intervention and control conditions (b1 = 4.06, t (55) = 6.11, p < 0.001; intervention M = 11.29, SE = 0.66, 95% CI, 9.99-12.59 vs control M = 7.23, SE = 0.46, 95% CI, 6.33-8.13, d = 0.92). Although patient care was similar between conditions (b = 2.00, t (55) = 0.99, p = 0.325; predicted means intervention M = 62.38, SE = 2.01, 95% CI, 58.43-66.33 vs control M = 60.38, SE = 1.37, 95% CI, 57.69-63.07, d = 0.15), a test of the mediation effect between training and patient care suggests leadership behaviors mediate an effect of training on patient care with a significant indirect effect (b = 3.44, 95% CI, 1.43-5.80). Across all trauma resuscitations leadership was significantly related to patient care (b1 = 0.61, SE = 0.15, t (273) = 3.64, p < 0.001).

CONCLUSIONS

Leadership training resulted in the transfer of complex skills to the clinical environment and may have an indirect effect on patient care through better team leadership.

A Forensic Aspect of Fetal Shoulder Dystocia

Fetal shoulder dystocia (FSD) is an unpredictable and critical obstetric intrapartum emergency, where an objective problem is the relationship between the mother's pelvis and the child, i. e., an anthropometric disorder of delivery mechanics and dynamics. It is evident that the need to perform other maneuvers indicates the severity of FSD, which in turn correlates with the consequent iatrogenic injury of the fetus and/or mother. FSD is certainly the most controversial forensic obstetric problem, with the most disputes, compensation for damages due to peripartum injury to the child and/or mother, pain suffered, the need for someone else's care, and permanent disability. Suboptimal procedures and inadequate documentation are factors of forensic risk and subsequent litigations. Prevention of FSD is generally not possible, although good antenatal care can sometimes exclude risky cases of FSD, and some rare, chronic intrauterine disorders can result in orthopedic and neurological sequelae, which is especially important in forensic analysis. Because FSD is largely impossible to predict, it must be viewed as an intrapartum acceptable risk. During childbirth, FSD may compromise the safety of the mother and unborn child, therefore education and skills acquisition are necessary for obstetric work. Risk control, proper procedures, and proper documentation, along with good communication with the pregnant women and their families, significantly reduce litigation procedures.

Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process

OBJECTIVES

There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety.

METHODS

An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems.

RESULTS

The expert group agreed on the following topics: technical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology.

CONCLUSIONS

The expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.

Using the Kirkpatrick Model to evaluate the Maternity and Neonatal Emergencies (MANE) programme: Background and study protocol

INTRODUCTION

Over 310 000 women gave birth in Australia in 2016, with approximately 80 000 births in the state of Victoria. While most of these births occur in metropolitan Melbourne and other large regional centres, a significant proportion of Victorian women birth in local rural health services. The Victorian state government recently mandated the provision of a maternal and neonatal emergency training programme, called Maternal and Newborn Emergencies (MANE), to rural and regional maternity service providers across the state. MANE aims to educate maternity and newborn care clinicians about recognising and responding to clinical deterioration in an effort to improve clinical outcomes. This paper describes the protocol for an evaluation of the MANE programme.

METHODS AND ANALYSIS

This study will evaluate the effectiveness of MANE in relation to: clinician confidence, skills and knowledge; changes in teamwork and collaboration; and consumer experience and satisfaction, and will explore and describe any governance changes within the organisations after MANE implementation. The Kirkpatrick Evaluation Model will provide a framework for the evaluation. The participants of MANE, 27 rural and regional Victorian health services ranging in size from approximately 20 to 1000 births per year, will be invited to participate. Baseline data will be collected from maternity service staff and consumers at each health service before MANE delivery, and at four time-points post-MANE delivery. There will be four components to data collection: a survey of maternity services staff; follow-up interviews with Maternity Managers at health services 4 months after MANE delivery; consumer feedback from all health services collected through the Victorian Healthcare Experience Survey; case studies with five regional or rural health service providers.

ETHICS AND DISSEMINATION

This evaluation has been approved by the La Trobe University Science, Health and Engineering College Human Ethics Sub-Committee. Findings will be presented to project stakeholders in a deidentified report, and disseminated through peer-reviewed publications and conference presentations.

The impact of maternity training on knowledge, confidence, and empowerment: A mixed method pilot evaluation

RATIONALE, AIMS, AND OBJECTIVES

Maternity training is a critical global issue. In the United Kingdom (UK), the need for safer care and patient safety is emphasized through NHS policy. Health Education England (HEE) recommends that training should support a culture of continuous learning and improvement, particularly in the area of reducing the rates of stillbirths, neonatal and maternity deaths, and other adverse outcomes, such as intrapartum brain injuries. Training has been shown to play a crucial role in improving quality of care and reducing maternal and perinatal mortality and morbidity. This evaluation was undertaken to determine both the immediate and sustained impact of multiprofessional training in cardiotocograph (CTG) interpretation and community-based simulation training in obstetric emergencies: childbirth emergencies in the community (CEC). The impact was measured in terms of practitioner knowledge, confidence, and empowerment immediately pretraining and posttraining and at 12 weeks following training.

METHODS

A longitudinal mixed methods design was used. Attendees to maternity training sessions on cardiotocograph interpretation and management of childbirth emergencies in the community provided the sample. Quantitative data were collected using questionnaires to assess knowledge, confidence, and empowerment. Qualitative data were collected using open-ended questions embedded in the questionnaires. Quantitative data were analysed using within-subject t test to compare differences in the dependent variable measures. Qualitative data analysis was guided by Braun and Clarke (2013) method thematic analysis.

RESULTS

The combined qualitative and quantitative results lucidly highlight that training positively impacts upon knowledge, confidence, and empowerment, an impact which is observed across three time points.

CONCLUSIONS

Training in CTG and CEC is effective in improving knowledge, confidence, and empowerment across all groups. Furthermore, the provision of training packages in these subject areas facilitates improvements in the longer term.

The use of a hybrid mannequin for the modern high-fidelity simulation in the labor ward: the Italian experience of the Ecografia Gestione Emergenze Ostetriche (EGEO) group

Regular training in the management of intrapartum emergencies has been demonstrated to yield measurable benefits in terms of maternal and perinatal outcomes. Thanks to technologic advances, computerized, full-body mannequins have been created and made available for high-fidelity simulation in obstetrics. The technical skills subjected to training are conventionally represented by classical manual maneuvers, which are recommended in the case of instrumental vaginal delivery, shoulder dystocia, or postpartum hemorrhage. During the past few years, manual skills in the labor ward have been increasingly supported by the use of ultrasound, and this has substantially altered the practical management of intrapartum emergencies in real life. Based on this, a new generation of mannequins suitable for both clinical maneuvers and ultrasound examination seems to be the most appropriate tool for the modern high-fidelity simulation in the management of intrapartum complications. The use of these new hybrid clinical ultrasound mannequins may usher in a new era in high-fidelity obstetric simulation and can hopefully optimize the competencies and technical skills of labor ward professionals in the management of obstetric emergencies. It is from this background that at the beginning of 2018, the Ecografia Gestione Emergenze Ostetriche group was founded in Italy. This group has aggregated a multiprofessional labor ward team including obstetricians, midwives, and anesthesiologists under the common philosophy that ultrasound provides an essential added value in the management of obstetric emergencies. Thanks to the use of these mannequins, the multiprofessional Italian Ecografia Gestione Emergenze Ostetriche group has started to run practical workshops to promote the culture of extraordinary synergy of ultrasound and clinical skills as the best approach to handle intrapartum complications.