Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training

Risk factors analysis and multidisciplinary team first-aid simulation training for umbilical cord prolapse can improve neonatal outcomes

OBJECTIVE

In the present study, we sought to identify risk factors for umbilical cord prolapse (UCP) and adapt the multidisciplinary team (MDT) first-aid simulation training for UCP patients. We evaluated the usefulness of the MDT first-aid simulation by comparing delivery outcomes for UCP patients before and after its implementation.

MATERIAL AND METHODS

A retrospective review was conducted on 149 UCP cases (48 overt and 101 occult) and 298 control deliveries that occurred at the Third Affiliated Hospital of Sun Yat-sen University from January 1998 to December 2022. Patient data were compared between the groups. One-way analysis of variance (ANOVA) was used for means comparison, and the chi-square test was used for categorical data. Univariate and multivariate logistic regression analyses were performed to identify factors significantly associated with UCP.

RESULTS

Overt UCP was strongly associated with all adverse delivery outcomes. Both univariate and multivariate analyses identified multiparity, breech presentation, polyhydramnios, and low birth weight as independent risk factors for overt UCP (all odds ratios [OR] > 1; all p < 0.05). Preterm labor and abnormal placental cord insertion were identified as independent risk factors for occult UCP (all OR > 1; all p < 0.05). After 2014, when obstetrical staff received MDT first-aid simulation training, patients with overt UCP experienced shorter decision-to-delivery intervals due to more timely cesarean sections. They also had higher Apgar scores at 1, 5, and 10 min, and lower admission rates to the neonatal intensive care unit compared to patients before 2014 (all p < 0.05).

CONCLUSION

MDT first-aid simulation training for overt UCP can improve neonatal outcomes. However, medical simulation training efforts should initially focus on the early identification of risk factors for both overt and occult UCP.

Virtual simulation training for postpartum hemorrhage in low-to-moderate-volume hospitals in the US

Background

Maternal mortality in the United States is rising and many deaths are preventable. Emergencies, such as postpartum hemorrhage, occur less frequently in non-teaching, rural, and urban low-birth volume hospitals. There is an urgent need for accessible, evidence-based, and sustainable inter-professional education that creates the opportunity for clinical teams to practice their response to rare, but potentially devastating events.

Objective

To assess the feasibility of virtual simulation training for the management of postpartum hemorrhage in low-to-moderate-volume delivery hospitals.

Study design

The study occurred between December 2021 and March 2022 within 8 non-academic hospitals in the United States with low-to-moderate-delivery volumes, randomized to one of two models: direct simulation training and train-the-trainer. In the direct simulation training model, simulation faculty conducted a virtual simulation training program with participants. In the train-the-trainer model, simulation faculty conducted virtual lessons with new simulation instructors on how to prepare and conduct a simulation course. Following this training, the instructors led their own simulation training program at their respective hospitals. The direct simulation training participants and students trained by new instructors from the train-the-trainer program were evaluated with a multiple-choice questionnaire on postpartum hemorrhage knowledge and a confidence and attitude survey at 3 timepoints: prior to, immediately after, and at 3 months post-training. Paired t-tests were performed to assess for changes in knowledge and confidence within teaching models across time points. ANOVA was performed to test cross-sectionally for differences in knowledge and confidence between teaching models at each time point.

Results

Direct simulation training participants (n=22) and students of the train-the-trainer instructors (n=18) included nurses, certified nurse midwives and attending physicians in obstetrics, family practice or anesthesiology. Mean pre-course knowledge and confidence scores were not statistically different between direct simulation participants and the students of the instructors from the train-the-trainer course (79%+/-13 versus 75%+/-14, respectively, P-value=.45). Within the direct simulation group, knowledge and confidence scores significantly improved from pre- to immediately post-training (knowledge score mean difference 9.81 [95% CI 3.23-16.40], P-value<.01; confidence score mean difference 13.64 [95% CI 6.79-20.48], P-value<.01), which were maintained 3-months post-training. Within the train-the-trainer group, knowledge and confidence scores immediate post-intervention were not significantly different compared with pre-course or 3-month post-course scores. Mean knowledge scores were significantly greater for the direct simulation group compared to the train-the-trainer group immediately post-training (89%+/-7 versus 74%+/-8, P-value<.01) and at 3-months (88%+/-7 versus 76%+/-12, P-value<.01). Comparisons between groups showed no difference in confidence and attitude scores at these timepoints. Both direct simulation participants and train-the-trainer instructors preferred virtual education, or a hybrid structure, over in-person education.

Conclusion

Virtual education for obstetric simulation training is feasible, acceptable, and effective. Utilizing a direct simulation model for postpartum hemorrhage management resulted in enhanced knowledge acquisition and retention compared to a train-the-trainer model.

Simulation training for pelvic examination: A systematic review

OBJECTIVE

Pelvic examination including vaginal digital examination and speculum inspection are crucial medical skills that are challenging to teach for both professors and students, because of its intimate nature. Consequently, education has shifted from a traditional approach to a simulation-enhanced education. This literature review summarizes the level of evidence for these not-so-new training modalities.

METHODS

For this systematic review, the Pudmed database have been consulted using the following keywords: (Pelvic examination OR Vaginal examination) AND simulation. Eligible studies had to be published in French or English within the past 20 years and investigate simulation training for pelvic examination in the field of gynecology and obstetrics. For each paper, the following outcomes were analyzed: Competence, confidence and communication, and were classified according to the Kirkpatrick hierarchy.

RESULTS

About competence, in initial training, one meta-analysis (9 studies of which 4 randomized studies) about pelvic examination teaching on procedural simulators have shown a significant benefit of simulation. One meta-analysis and one systematic review also demonstrated that Gynecological Teaching Associates (GTAs) teaching, who exist in Northern America and Scandinavian countries, was better that pelvic task trainers in terms of technical competence, and comfort. For the vaginal examination of women in labor, two randomized trials also showed a positive impact of pelvic task trainer on students' accuracy.

CONCLUSION

Simulation-enhanced education of pelvic examination brings a significant benefit in comparison to a classic education without simulation in terms of competence, confidence and communication. GTAs have the best impact on competence and communication, but they do not exist currently in France. Hybrid simulation (a patient actor combined with a pelvic task trainer) could be a solution to teach both technical skills and communication.

Effect of in situ simulation training for emergency caesarean section on maternal and infant outcomes

BACKGROUND

Emergency caesarean section (ECS) is an effective method for rapid termination of pregnancy and for saving maternal and foetal life in emergencies. Experts recommend that the interval from decision of operation to the decision to delivery interval (DDI) should be shortened as much as possible. Studies have shown that improving communication skills among staff by performing simulation drills shortens DDI, thus reducing the occurrence of adverse obstetric events and protecting maternal and child safety. In situ simulation (ISS) training is a simulation-based training approach for clinical team members conducted in a real-world clinical setting. In August 2020, Anhui Maternal and Child Health Hospital began ISS training on the rapid obstetric response team (RRT) in our hospital area for emergency caesarean section. This study aimed to investigate the effect of implementing in situ simulation training for emergency caesarean section on maternal and child outcomes by comparing maternal and child-related data on emergency caesarean section in two hospital areas.

METHODS

Data on cases of emergency caesarean delivery implemented in two hospital districts from August 2020 to August 2022 were collected: 19 in the untrained group and 26 in the training group. The two groups were compared concerning the interval from the decision of operation to the decision to delivery interval (DDI), the interval from the decision of operation to the initiation of skin incision, the interval from skin incision to the decision to delivery interval, and the neonatal situation.

RESULTS

Primary outcome comparison: The training group had a significantly shorter interval between the DDI compared to the untrained group (8.14 ± 3.13 vs. 11.03 ± 3.52, P = 0.006). Secondary outcomes comparison: The training group had a significantly shorter interval between the decision to cut skin compared to the untrained group (6.45 ± 2.21 vs. 9.95 ± 4.02, P = 0.001). However, there was no significant difference in the interval between cutting skin and infant delivery between the two groups (2.24 ± 0.08 vs. 2.18 ± 0.13, P > 0.05). Additionally, the Apgar score at 1 min after birth was higher in the training group compared to the untrained group (7.29 ± 2.38 vs. 6.04 ± 1.46, P < 0.05).

CONCLUSIONS

The DDI for emergency caesarean section procedures can be significantly shortened, and neonatal Apgar scores at 1 min improved by implementing in situ simulation training for emergency caesarean section in obstetric rapid response teams. In situ simulation training is an effective tool for training in emergency caesarean section procedures and is worth promoting.

Decision-to-delivery interval and neonatal outcomes in intrapartum umbilical cord prolapse

BACKGROUND

Rapid delivery is important in cases of umbilical cord prolapse to prevent hypoxic injury to the fetus/neonate. However, the optimal decision-to-delivery interval remains controversial.

OBJECTIVE

The aim of the study was to investigate the association between the decision-to-delivery interval in women with umbilical cord prolapse, stratified by fetal heart rate pattern at diagnosis, and neonatal outcome.

STUDY DESIGN

The database of a tertiary medical center was retrospectively searched for all cases of intrapartum cord prolapse between 2008 and 2021. The cohort was divided into three groups according to findings on the fetal heart tracing at diagnosis: 1) bradycardia; 2) decelerations without bradycardia; and 3) reassuring heart rate. The primary outcome measure was fetal acidosis. The correlation between cord blood indices and decision-to-delivery interval was analyzed using Spearman's rank correlation coefficient.

RESULTS

Of the total 103,917 deliveries performed during the study period, 130 (0.13%) were complicated by intrapartum umbilical cord prolapse. Division by fetal heart tracing yielded 22 women (16.92%) in group 1, 41 (31.53%) in group 2, and 67 (51.53%) in group 3. The median decision-to-delivery interval was 11.0 min (IQR 9.0-15.0); the interval was more than 20 min in 4 cases. The median cord arterial blood pH was 7.28 (IQR 7.24-7.32); pH was less than 7.2 in 4 neonates. There was no correlation of cord arterial pH with decision-to-delivery interval (Spearman's Ρ =  - 0.113; Ρ = 0.368) or with fetal heart rate pattern (Spearman's Ρ = .425; Ρ = .079, Ρ =  - .205; Ρ = .336, Ρ =  - .324; Ρ = .122 for groups 1-3, respectively).

CONCLUSION

Intrapartum umbilical cord prolapse is a relatively rare obstetric emergency with an overall favorable neonatal outcome if managed in a timely manner, regardless of the immediately preceding fetal heart rate. In a clinical setting which includes a high obstetric volume and a rapid, protocol-based, response, there is apparently no significant correlation between decision-to-delivery interval and cord arterial cord pH.

Assessment of compliance with a color code protocol for non-elective cesarean section and its impact on time to delivery interval and neonatal outcomes

INTRODUCTION

We set out to assess the compliance with a cesarean section color code protocol and its impact on maternal and neonatal outcomes since its implementation in our maternity ward.

METHODS

This was a retrospective study including a sample of 200 patients per year who underwent a non-elective cesarean section delivery in Rennes University Hospital from January 1, 2015 to December 31, 2018. Patients were grouped by year and by color code (red, orange or green). The main outcome was compliance with the protocol (color code in accordance with indication for cesarean section) and compliance with the corresponding decision-delivery interval. Secondary outcomes were maternal and neonatal outcomes.

RESULTS

Eight hundred patients were included during the study period. There was no significant difference in patient characteristics over the years. There was a significant improvement in protocol compliance: full compliance increased from 22.4% in 2015 to 76.5% in 2018 (p < 0.0001). The respect of the 15 min decision-delivery interval in red code protocol increased between 2015 and 2018 (p = 0.0020).

CONCLUSION

We observed a significant improvement in compliance with the color code protocol between 2015 and 2018 and in the 15 min decision-delivery deadline for the red code.

Communication Patterns During Routine Patient Care in a Pediatric Intensive Care Unit: The Behavioral Impact of In Situ Simulation

OBJECTIVE

Effective communication minimizes medical errors and leads to improved team performance while treating critically ill patients. Closed-loop communication is routinely applied in high-risk industries but remains underutilized in healthcare. Simulation serves as an educational tool to introduce, practice, and appreciate the efficacy of closed-loop communication.

METHODS

This observational before-and-after study investigates behavioral changes in communication among nurses brought on by simulation team training in a pediatric intensive care unit (PICU). The communication patterns of PICU nurses, who had no prior simulation experience, were observed during routine bedside care before and after undergoing in situ simulation.One month before and 1 and 3 months after simulation (intervention), 2 trained raters recorded nurse communications relative to callouts, uttered by the sender, and callbacks, reciprocated by the recipient. The impact of simulation on communication patterns was analyzed quantitatively.

RESULTS

Among the 15 PICU nurses included in this study, significant changes in communication behavior were observed during patient care after communication-focused in situ simulation. The PICU nurses were significantly less likely to let a callout go unanswered during clinical routine. The effect prevailed both 1 month (P = 0.039) and 3 months (P = 0.033) after the educational exposure.

CONCLUSIONS

This observational before-and-after study describes the prevalence and pattern of communication among PICU nurses during routine patient care and documents PICU nurses transferring simulation-acquired communication skills into their clinical environment after a single afternoon of in situ simulation. This successful transfer of simulation-acquired skills has the potential to improve patient safety and outcome.

Simulation and beyond - Principles of effective obstetric training

Simulation training provides a safe, non-judgmental environment where members of the multi-professional team can practice both their technical and non-technical skills. Poor teamwork and communication are recurring contributing factors to adverse maternal and neonatal outcomes. Simulation can improve outcomes and is now a compulsory part of the national training matrix. Components of successful training include involving the multi-professional team, high fidelity models, keeping training on-site, and focussing on human factors training; a key factor in adverse patient outcomes. The future of simulation training is an exciting field, with the advent of augmented reality devices and the use of artificial intelligence.

Staying alive-training with anaesthetists

An effective working relationship between obstetricians and anaesthetists is crucial for patient safety in maternity care. Anaesthetists' skills and scope of clinical practice complement those of obstetricians, particularly during obstetric emergencies. Anaesthetists also bring expertise in resuscitation, critical care, and a training programme that is underpinned by non-technical as well as technical skills. Through training together, obstetricians and anaesthetists can help plug one another's knowledge gaps, identify each other's blind spots, aid mutual decision-making, and share relevant national guidance between specialties. Training also aids the development of a shared mental model, which contributes to improved teamwork. To be effective, this training should involve the whole team, be conducted in-house, be used to tackle local as well as national priorities, and be repeated regularly.

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.

The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis

INTRODUCTION

Little is known about the optimal simulation-based team training in obstetric emergencies. We aimed to review how simulation-based team training affects patient outcomes in obstetric emergencies.

MATERIAL AND METHODS

Search Strategy: MEDLINE, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were searched up to and including May 15, 2021.

SELECTION CRITERIA

randomized controlled trials (RCTs) and cohort studies on obstetric teams in high-resource settings comparing the effect of simulation-based obstetric emergency team training with no training on the risk of Apgar scores less than 7 at 5 min, neonatal hypoxic ischemic encephalopathy, severe postpartum hemorrhage, blood transfusion of four or more units, and delay of emergency cesarean section by more than 30 min.

DATA COLLECTION AND ANALYSIS

The included studies were assessed using PRISMA, EPCO, and GRADE.

RESULTS

We found 21 studies, four RCTs and 17 cohort studies, evaluating patient outcomes after obstetric team training compared with no training. Annual obstetric emergency team training may reduce brachial plexus injury (six cohort studies: odds ratio [OR] 0.47, 95% CI 0.33-0.68; one RCT: OR 1.30, 95 CI% 0.39-4.33, low certainty evidence) and suggest a positive effect; but it was not significant on Apgar score below 7 at 5 min (three cohort studies: OR 0.77, 95% CI 0.51-1.19; two RCT: OR 0.87, 95% CI 0.72-1.05, moderate certainty evidence). The effect was unclear for hypoxic ischemic encephalopathy, umbilical prolapse, decision to birth interval in emergency cesarean section, and for severe postpartum hemorrhage. Studies with in situ multi-professional simulation-based training demonstrated the best effect.

CONCLUSIONS

Emerging evidence suggests an effect of obstetric team training on obstetric outcomes, but conflicting results call for controlled trials targeted to identify the optimal methodology for effective team training.

Umbilical cord prolapse: revisiting its definition and management

Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal mortality, ranging from 23% to 27% in low-income countries to 6% to 10% in high-income countries. In this review, we specifically addressed 3 issues. First, its definition is not consistent in the current literature, and "occult cord prolapse" is a misnomer because the cord is still above the cervix. We proposed that cord prolapse, cord presentation, and compound cord presentation should be classified according to the positional relationship among the cord, the fetal presenting part, and the cervix. All of them may occur with either ruptured or intact membranes. The fetal risk is highest in cord prolapse, followed by cord presentation, and lastly by compound cord presentation, which replaces the misnomer "occult cord prolapse." Second, the mainstay of treatment of cord prolapse is urgent delivery, which means cesarean delivery in most cases, unless vaginal delivery is imminent. The urgency depends on the fetal heart rate pattern, which can be bradycardia, recurrent decelerations, or normal. It is most urgent in cases with bradycardia, because a recent study showed that cord arterial pH declines significantly with the bradycardia-to-delivery interval at a rate of 0.009 per minute (95% confident interval, 0.0003-0.0180), and this may indicate an irreversible pathology such as vasospasm or persistent cord compression. However, cord arterial pH does not correlate with either deceleration-to-delivery interval or decision-to-delivery interval, indicating that intermittent cord compression causing decelerations is reversible and less risk. Third, while cesarean delivery is being arranged, different maneuvers should be adopted to relieve cord compression by elevating the fetal presenting part and to prevent further cord prolapse beyond the vagina. A recent study showed that the knee-chest position provides the greatest elevation effect, followed by filling of the maternal urinary bladder with 500 mL of fluid, and then the Trendelenburg position (15°) and other maneuvers. However, each maneuver has its own advantages and limitations; thus, they should be applied wisely and with great caution, depending on the actual clinical situation. Therefore, we have proposed an algorithm to guide this acute management.

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.

Impact of simulation training on decision to delivery interval in cord prolapse

Background

Umbilical cord prolapse is a rare obstetric emergency requiring rapid coordination of a multidisciplinary team to effect urgent delivery. The decision to delivery interval (DDI) is a marker of quality of teamwork. Multidisciplinary team simulation-based training can be used to improve clinical and teamwork performance.

Aim

To assess the DDI for cord prolapse before and after the introduction of simulation-based training at a quaternary maternity unit in Australia.

Method

A retrospective, observational cohort study comparing the DDI before and after the introduction of simulation-based training activities. The general linear model was used to estimate the association between DDI and simulation training while adjusting for potential confounders including model of care (public or private) and time of birth (regular or after hours).

Results

After the introduction of simulation training, mean DDI decreased by 4.1 min (difference −4.1, 95% CI −6.2 to −1.9), after adjustment for confounding factors. Despite this, there was no difference in selected neonatal outcomes including Apgar score at 5 min and arterial cord pH.

Conclusions

The introduction of simulation-based training was associated with a decrease in the DDI in the setting of cord prolapse.

Umbilical Cord Prolapse: A Review of the Literature

Importance

Umbilical cord prolapse is a rare occurrence and is a life-threatening emergency for the fetus. These events are unpredictable and unpreventable. Umbilical cord prolapse requires swift diagnosis and management for optimal outcome.

Objective

The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of this rare but potentially life-threatening event.

Evidence Acquisition

A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched.

Results

There were 200 articles identified, with 53 being the basis of review. Multiple risk factors for a umbilical cord prolapse have been suggested including fetal malpresentation or abnormal lie, prematurity, multifetal gestation, and polyhydramnios. The diagnosis is largely made by examination and found after rupture of membranes, and most often, examination is prompted by fetal heart rate decelerations. The management of umbilical cord prolapse is expedited delivery; however, there are rare specific scenarios in which immediate delivery is not possible and efforts should be made to relieve cord compression.

Conclusions

Rapid identification of an umbilical cord prolapse facilitates management and increases likelihood of an optimal outcome. The management is an expedited delivery with efforts to relieve cord compression until delivery can be achieved.

Relevance

Umbilical cord prolapse is a rare but a life-threatening obstetrical emergency.

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.

Evaluation of Simulation Outcomes

Simulation has been used in nursing education and training since Florence Nightingale's era. Over the past 20 years, simulation learning experiences (SLEs) have been used with increasing frequently to educate healthcare professionals, develop and increase the expertise of practicing professionals, and gain competency in key interprofessional skills. This chapter provides a brief overview of simulation evaluation history, beginning in the late 1990s, and the initial focus on learner self-report data. Using Kirkpatrick's Levels of Evaluation as an organizing model, four types of SLE evaluation are reviewed as well as suggestions for future research.

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.

Cognitive aids with roles defined (CARD) for obstetrical crises: a multisite before-and-after cohort study

PURPOSE

Patient outcome during an obstetrical emergency depends on prompt coordination of an interprofessional team. The cognitive aids with roles defined (CARD) is a cognitive aid that addresses the issue of teamwork in crisis management. This study evaluated the clinical impact of implementing the CARD cognitive aid during emergency Cesarean deliveries.

METHODS

We conducted a prospective before-and-after cohort trial at the maternity units of two Canadian academic hospital campuses. Both sites received didactic online training regarding teamwork during crises, which involved training on using CARD for the "CARD" campus (intervention) and no mention of CARD at the "no CARD" campus (control). The primary outcome was the total time to delivery after the call for an emergency Cesarean delivery. Secondary outcomes included specific intervals of time within the time to delivery and clinical outcomes for both the babies and mothers.

RESULTS

We analyzed data from 267 eligible emergency Cesarean deliveries that occurred between January 11 2014 and December 31 2017. The use of CARD did not significantly change the median [interquartile range] time to delivery of the baby during an emergency Cesarean delivery from the pre-intervention to the post-intervention time period (17 [12-28] vs 15 [13-20], respectively; median difference, 2; 95% confidence interval, -1 to 5; P = 0.36). The clinical outcomes for the baby or the mother and other secondary outcomes also did not change.

CONCLUSIONS

The CARD cognitive aid did not significantly improve time-based or clinical maternal and neonatal outcomes of emergency Cesarean delivery at our academic maternity unit.

Randomized Controlled Simulation Trial to Compare Transfer Procedures for Emergency Cesarean

OBJECTIVE

To test the hypothesis that capping intravenous and epidural lines would reduce time to transfer women in labor to the operating room and time to readiness for general anesthesia for emergency cesarean. The secondary purpose was to identify latent threats to patient safety.

DESIGN

Mixed methods analysis of a randomized, controlled, in situ simulation trial.

SETTING

Labor and delivery unit at high-risk referral center.

PARTICIPANTS

Fifteen interprofessional teams that included labor and delivery nurses and anesthesiology residents.

METHODS

Immediately before simulation, we randomized bedside nurses and anesthesiology residents to one of two groups: usual transfer or the cap and run procedure. Simulation scenarios started with fetal heart rate decelerations that necessitated position changes followed by emergency cesarean. An embedded simulated obstetrician announced the decision for cesarean; completion of an OR checklist confirmed team readiness to induce general anesthesia. Postsimulation debriefing was focused on teamwork and opportunities to improve safety, and we used qualitative analysis to synthesize results.

RESULTS

We found no statistically significant difference in the overall time from decision for cesarean to readiness for general anesthesia between the two groups (usual transfer median = 445 seconds [interquartile range, 425-465] vs. cap and run 390 seconds [interquartile range, 383-443], p = .12). The time in the operating room was less in the cap and run group than in the usual transfer group (median = 300 seconds vs. 250 seconds, p = .038). Qualitative analysis of the debriefing data indicated advantages of the capping procedure, including better bed maneuverability and fewer tangled lines.

CONCLUSION

We found no evidence of decreased overall time from decision for cesarean to readiness for general anesthesia based on whether the nurse capped the intravenous and epidural lines or pushed the intravenous pole alongside the bed. However, nurses perceived improved patient safety with the cap and run procedure.

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.

Interventions to improve team effectiveness within health care: a systematic review of the past decade

BACKGROUND

A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.

OBJECTIVES

To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research.

METHODS

Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.

CONCLUSION

Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Hybrid simulation for obstetrics training: A systematic review

Hybrid simulation is defined as the use of a patient actor combined with a task trainer within the same session. We sought to investigate the level of evidence about the clinical benefits of hybrid simulation training in obstetrics. We searched MEDLINE using the keywords: Obstetrics AND Medical Education AND (Standardized patient OR Hybrid simulation). A total of 155 studies were screened, from which we selected 11 articles were selected from the title and the abstract in PubMed. For each study, data about the type of simulation, the level of evidence according KirkPatrick's hierarchy was collected. There is evidence that clinical benefit for patients exists for Shoulder Dystocia, and Cord prolapse. For Non-technical skills, such as communication or team training, hybrid simulation was also effective. Whether hybrid simulation offers better training for communication and better immersion than high-fidelity simulation for learners remains to be investigated.

Effect of hands-on interprofessional simulation training for local emergencies in Scotland: the THISTLE stepped-wedge design randomised controlled trial

OBJECTIVE

To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<7^5mins).

DESIGN

Stepped-wedge cluster randomised controlled trial.

SETTING

Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016.

INTERVENTION

The PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of term babies with Apgar<7^5mins.

RESULTS

87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<7^5mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<7^5mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the 'intention-to-treat' analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <7^5mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<7^5mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate.

CONCLUSIONS

PROMPT training, as implemented, had no effect on the rate of Apgar <7^5mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively.

TRIAL REGISTRATION NUMBER

ISRCTN11640515.

Emerging Role of Drills and Simulations in Patient Safety

Ensuring patient safety and optimizing outcomes in obstetrics and gynecology through improving technical skills, enhancing team performance, and decreasing medical errors has resulted in significant interest in incorporating drills and simulation into medical training, continuing education, and multidisciplinary team practice. Drills and simulations are ideal because of their wide range of application with various learners and settings. They provide a safe space to learn and maintain technical skills and to improve knowledge, confidence, communication, and teamwork behaviors, particularly for less common, high-stakes clinical scenarios.

Simulation-based educational package to improve delivery of the deeply impacted fetal head at caesarean section

Deeply impacted fetal head at caesarean section at full dilation is a rare obstetric emergency, and exposure for trainees can be limited. We aimed to pilot and evaluate a hospital-based training program incorporating mastery learning principles for trainees performing caesarean section at full dilation. We demonstrated improvements in knowledge, skills and self-confidence, and feel that this educational package shows promise as an important component of obstetric training, and warrants further exploration in the future.

How to be a very safe maternity unit: An ethnographic study

Maternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. As in other areas of healthcare, improvement efforts have typically focused either on implementing and evaluating specific interventions, or on identifying the contextual features that may be generative of safety (e.g. structures, processes, behaviour, practices, and values), but the dialogue between these two approaches has remained limited. In this article, we report a positive deviance case study of a high-performing UK maternity unit to examine how it achieved and sustained excellent safety outcomes. Based on 143 h of ethnographic observations in the maternity unit, 12 semi-structured interviews, and two focus groups with staff, we identified six mechanisms that appeared to be important for safety: collective competence; insistence on technical proficiency; monitoring, coordination, and distributed cognition; clearly articulated and constantly reinforced standards of practice, behaviour, and ethics; monitoring multiple sources of intelligence about the unit's state of safety; and a highly intentional approach to safety and improvement. These mechanisms were nurtured and sustained through both a specific intervention (known as the PROMPT programme) and, importantly, the unit's contextual features: intervention and context shaped each other in both direct and indirect ways. The mechanisms were also influenced by the unit's structural conditions, such as staffing levels and physical environment. This study enhances understanding of what makes a maternity unit safe, paving the way for better design of improvement approaches. It also advances the debate on quality and safety improvement by offering a theoretically and empirically grounded analysis of the interplay between interventions and context of implementation.

[Medical simulation as a tool in the training of perinatal professionals]

Though technology plays an increasingly important role in modern health systems, human performance remains a major determinant of safety, effectiveness and efficiency of patient care. This is especially true in the delivery room. Thus, the training of professionals must aim not only for the acquisition of theory and practical skills on an individual basis, but also for the learning of teamwork systematically. Training health professionals with simulation enhances their theoretical knowledge and meets formal requirements in literacy, technical skills and communication. Therefore, we intend to explore how, in perinatal care, training with simulation is actually a key teaching tool in initial education and in perpetuation of knowledge. We will approach three main aspects: individual, collective (team) and the impact of simulation in medical practice. The choice of this educational strategy improves the clinical skills that are required for optimal performance in complex, unpredictable and high-stake environments such as the delivery room. Nonetheless, the long term clinical impact of simulation and whether it's modalities, technical or not, are beneficial to the mother and the newborn are areas still to be explored.

Optimal management of umbilical cord prolapse

Umbilical cord prolapse (UCP) is an uncommon obstetric emergency that can have significant neonatal morbidity and/or mortality. It is diagnosed by seeing/palpating the prolapsed cord outside or within the vagina in addition to abnormal fetal heart rate patterns. Women at higher risk of UCP include multiparas with malpresentation. Other risk factors include polyhydramnios and multiple pregnancies. Iatrogenic UCP (up to 50% of cases) can occur in procedures such as amniotomy, fetal blood sampling, and insertion of a cervical ripening balloon. The perinatal outcome largely depends on the location where the prolapse occurred and the gestational age/birthweight of the fetus. When UCP is diagnosed, delivery should be expedited. Usually, cesarean section is the delivery mode of choice, but vaginal/instrumental delivery could be tried if deemed quicker, particularly in the second stage of labor. Diagnosis-to-delivery interval should ideally be less than 30 minutes; however, if it is expected to be lengthy, measures to relieve cord compression should be attempted. Manual elevation of the presenting part and Vago's method (bladder filling) are the most commonly used maneuvers. Care should be given not to cause cord spasm with excessive manipulation. Simulation training has been shown to improve/maintain all aspects of management and documentation. Prompt diagnosis and interventions and the positive impact of neonatal management have significantly improved the neonatal outcome.

Maternal Obstetric Complication Rates Remain High in Illinois: A Retrospective Study, 2010-2015

BACKGROUND

Quality measures for maternal childbirth outcomes remain controversial, although there is a consensus that maternal morbidity has been increasing in recent years. To determine whether childbirth safety has declined in Illinois, the likelihood of maternal obstetric complications was modeled by using both an established measure of severe maternal morbidity and a more expansive complication coding algorithm.

METHODS

In a retrospective cohort study of 792,122 deliveries at 127 Illinois hospitals from July 2010 to September 2015, International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify Centers for Disease Control and Prevention-defined severe maternal morbidity, as well as other maternal complications defined by a route of delivery-specific algorithm originally used to evaluate the quality of obstetrics residency programs. Poisson and logistic regression were used to analyze the likelihood of delivery complications during the study period, controlling for maternal sociodemographic and clinical characteristics.

RESULTS

The severe maternal morbidity rate was 0.99% for vaginal and 3.76% for cesarean deliveries. The maternal complication rates were much higher-9.44% for vaginal and 14.66% for cesarean deliveries. After controlling for patient characteristics, severe maternal morbidity remained constant, but there was a statistically significant, approximately 20% increase in the incidence of other maternal complications from 2010 to 2015 for both vaginal and cesarean deliveries.

CONCLUSION

Severe maternal morbidity remained stable during the study period, but other maternal complications increased significantly. Severe maternal morbidity may undercount potentially preventable complications. New, more reliable measures of preventable delivery complications may have to be based on electronic health record standards.

Medium-fidelity simulation in clinical readiness: a phenomenological study of student midwives concerning teamwork

Background

Teamwork during obstetric emergency ensures good outcomes for both the woman and her baby. Effective teams are characterised by mutual respect, support, and cooperation among team members.

Methods

This qualitative, interpretive, phenomenological analysis study was conducted on a purposive sample of five, fourth-year Bachelor of Nursing Science student midwives at the University of Fort Hare (UFH). In-depth semi-structured interviews were conducted. Data analysis applied the interpretative phenomenological analysis method.

Results

Superordinate theme demonstrated teamwork elicited four clustered themes namely delegation of duties, the importance of teamwork, team support, and confident team leader. The participants recognised that there should be a team leader who is capable of delegating duties to other team members in the management of an obstetric emergency, Participants were confident not only to assign duties but to be kept updated of the intervention. They expressed the need to work collaboratively as a team to achieve the desired goal of providing quality care to the woman. The participants maintained that the team must be supportive and be able to help in decision making during simulation of an obstetric emergency. A sense of mutual respect is echoed by some participants in the process of caring for the woman. Some participants were confident at being team leaders and could see themselves as leaders in the real-life clinical situation.

Conclusion

The participants acknowledge the importance of teamwork in resolving obstetric emergencies. The importance of delegating duties to other team members, providing updated progress report ensures better outcomes for the woman.

Successful Use of Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease. How Do High-Performing Hospitals Do It?

RATIONALE

Noninvasive ventilation (NIV) is a cornerstone of treatment for patients with severe exacerbations of chronic obstructive pulmonary disease (COPD), where it has been shown to reduce the need for intubation, hospital length of stay, and mortality. Despite high-quality evidence and strong recommendations in clinical guidelines, use of NIV varies widely across hospitals.

OBJECTIVES

To identify approaches used by hospitals that have been successful in implementing NIV to treat patients with severe exacerbations of COPD.

METHODS

Adopting a positive deviance approach, in-depth interviews were conducted with key stakeholders from a sample of high-performing hospitals selected from a large and representative network of 386 U.S. hospitals. High performers were defined as hospitals in which a high proportion of patients with COPD requiring mechanical ventilation were treated with NIV, and that also achieved low risk-adjusted mortality for all patients with COPD. Interviews were audio-recorded and transcribed verbatim. Themes and subthemes were identified through iterative readings of the transcripts and discussion until the team agreed that all important themes and subthemes had been identified. All transcripts were coded by three or four researchers. Differences in coding were discussed to negotiate consensus, resulting in a single agreed-on set of coded transcripts.

RESULTS

Interviews were conducted with 32 participants from seven hospitals. Hospitals were diverse regarding size, teaching status, and geographic location. Participants included respiratory therapists (n = 15), physicians (n = 10), and nurses (n = 7). The qualitative analyses revealed three interrelated domains that characterized effective NIV use: processes, structural elements, and contextual factors. Several themes comprised each domain. Key processes included timely identification of appropriate patients, early initiation of NIV, frequent reassessment of patients, and attention to patient comfort. Necessary structural elements included adequate equipment, sufficient numbers of qualified respiratory therapists, and flexibility in staffing. Important contextual factors included provider buy-in, respiratory therapist autonomy, interdisciplinary teamwork, and staff education. Hospital leaders, policies, and protocols were identified as playing a supporting role in promoting essential elements.

CONCLUSIONS

We identified factors, such as respiratory therapist autonomy, that facilitated essential processes (e.g., timely initiation) of NIV use at high-performing hospitals. These findings may be useful to hospitals seeking to optimize their use of NIV among patients with COPD.

Intrapartum factors associated with neonatal hypoxic ischemic encephalopathy: a case-controlled study

BACKGROUND

Neonatal encephalopathy (NE) affects 2-4/1000 live births with outcomes ranging from negligible neurological deficits to severe neuromuscular dysfunction, cerebral palsy and death. Hypoxic ischemic encephalopathy (HIE) is the sub cohort of NE that appears to be driven by intrapartum events. Our objective was to identify antepartum and intrapartum factors associated with the development of neonatal HIE.

METHODS

Hospital databases were searched using relevant diagnosis codes to identify infants with neonatal encephalopathy. Cases were infants with encephalopathy and evidence of intrapartum hypoxia. For each hypoxic ischemic encephalopathy case, four controls were randomly selected from all deliveries that occurred within 6 months of the case.

RESULTS

Twenty-six cases met criteria for hypoxic ischemic encephalopathy between 2002 and 2014. In multivariate analysis, meconium-stained amniotic fluid (aOR 12.4, 95% CI 2.1-144.8, p = 0.002), prolonged second stage of labor (aOR 9.5, 95% CI 1.0-135.3, p = 0.042), and the occurrence of a sentinel or acute event (aOR 74.9, 95% CI 11.9-infinity, p < 0.001) were significantly associated with hypoxic ischemic encephalopathy. The presence of a category 3 fetal heart rate tracing in any of the four 15-min segments during the hour prior to delivery (28.0% versus 4.0%, p = 0.002) was more common among hypoxic ischemic encephalopathy cases.

CONCLUSION

Prolonged second stage of labor and the presence of meconium-stained amniotic fluid are risk factors for the development of HIE. Close scrutiny should be paid to labors that develop these features especially in the presence of an abnormal fetal heart tracing. Acute events also account for a substantial number of HIE cases and health systems should develop programs that can optimize the response to these emergencies.

THISTLE: trial of hands-on Interprofessional simulation training for local emergencies: a research protocol for a stepped-wedge clustered randomised controlled trial

Background

Many adverse pregnancy outcomes in the UK could be prevented with better intrapartum care. Training for intrapartum emergencies has been widely recommended but there are conflicting data about their effectiveness. Observational studies have shown sustained local improvements in perinatal outcomes associated with the use of the PRactical Obstetric Multi-Professional Training – (PROMPT) training package. However this effect needs to be investigated in the context of randomised study design in settings other than enthusiastic early adopter single-centres. The main aim of this study is to determine the effectiveness of PROMPT to reduce the rate of term infants born with low APGAR scores.

Methods

THISTLE (Trial of Hands-on Interprofessional Simulation Training for Local Emergencies) is a multi-centre stepped-wedge clustered randomised controlled superiority trial conducted across 12 large Maternity Units in Scotland. On the basis of prior observational findings all Units have been offered the intervention and have been randomly allocated in groups of four Units, to one of three intervention time periods, each six months apart.

Teams of four multi-professional clinicians from each participating Unit attended a two-day PROMPT Train the Trainers (T3) programme prior to the start of their allocated intervention step. Following the T3 training, the teams commenced the implementation of local intrapartum emergency training in their own Units by the start of their allocated intervention period. Blinding has not been possible due to the nature of the intervention. The aim of the study is to follow up each Unit for at least 12-months after they have commenced their local courses.

The primary outcome for the study is the proportion of Apgar scores <7 at 5 min for term vaginal or emergency caesarean section births (≥37 weeks) occurring in each of the study Units. These data will be extracted from the Information Services Division Scottish Morbidity Record 02, a national routine data collection on pregnancy and births. Mixed or marginal logistic regression will be employed for the main analysis.

Discussion

THISTLE is the first stepped wedge cluster randomised trial to evaluate the effectiveness of an intrapartum emergencies training programme. The results will inform training, trainers and policy going forward.

Trial registration

ISRCTN11640515 (registered on 09/09/2013).

Perinatal death associated with umbilical cord prolapse

OBJECTIVE

Umbilical cord prolapse occurs when the cord prolapses ahead of or alongside the presenting part. It is an acute obstetric emergency with potential catastrophic effects. We set out to assess incidence of cord prolapse, as well as rates and characteristics of perinatal death associated with the condition.

STUDY DESIGN

This was a retrospective cohort study. All recorded cases of cord prolapse were included, and rates of perinatal death and encephalopathy, as well as intrapartum and maternal characteristics were examined.

RESULTS

There were 156,130 deliveries at the hospital over the 20-year study period. Three hundred and seven cases of cord prolapse were identified (1.9/1000 deliveries). There was a decrease in the incidence of cord prolapse over the course of the study. The rate peaked in 1999 at 3.9/1000 and was just 0.8/1000 of all deliveries in 2007. The majority of cases (216/307, 70%) occurred in multiparas; however, nulliparous parturients were more likely to have a perinatal death [12% (11/91) vs. 4.6% (10/216)]. The rate of perinatal death in cases of cord prolapse was 6.8% (21/307). Over half of perinatal deaths (11/21) occurred in infants of mothers who presented with ruptured membranes, seven of these infants were already dead on reaching hospital. There was just one case of neonatal encephalopathy associated with cord prolapse, giving an incidence of 0.32%.

CONCLUSION

Cord prolapse carries a significant risk of perinatal death, approximately 7%. The corresponding rate of encephalopathy is low. A significant number of deaths were diagnosed on presentation to hospital and were not deemed preventable.

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. J van de Ven, AF Fransen, E Schuit, PJ van Runnard Heimel, BW Mol, SG Oei OBJECTIVE: To investigate whether the effect of a one-day simulation-based obstetric team training on patient outcome changes over time.

STUDY DESIGN

Post-hoc analysis of a multicentre, open, randomised controlled trial that evaluated team training in obstetrics (TOSTI study).We studied women with a singleton pregnancy beyond 24 weeks of gestation in 24 obstetric units. Included obstetric units were randomised to either a one-day, multi-professional simulation-based team training focusing on crew resource management in a medical simulation centre (12 units) or to no team training (12 units). We assessed whether outcomes differed between both groups in each of the first four quarters following the team training and compared the effect of team training over quarters. Primary outcome was a composite outcome of low Apgar score, severe postpartum haemorrhage, trauma due to shoulder dystocia, eclampsia and hypoxic-ischemic encephalopathy.

RESULTS

During a one year period after the team training the rate of obstetric complications, both on the composite level and the individual component level, did not differ between any of the quarters. For trauma due to shoulder dystocia team training led to a significant decrease in the first quarter (0.06% versus 0.26%, OR 0.19, 95% CI 0.03 to 0.98) but in the subsequent quarters no significant reductions were observed. Similar results were found for invasive treatment for severe postpartum haemorrhage where a significant increase was only seen in the first quarter (0.4% versus 0.03%, OR 19, 95% CI 2.5-147), and not thereafter.

CONCLUSION

The beneficial effect of a one-day, simulation-based, multiprofessional, obstetric team training seems to decline after three months. If team training is further evaluated or implemented, repetitive training sessions every three months seem therefore recommended.

Attending Physician Adherence to a 29-Component Central Venous Catheter Bundle Checklist During Simulated Procedures

OBJECTIVES

Central venous catheter insertions may lead to preventable adverse events. Attending physicians' central venous catheter insertion skills are not assessed routinely. We aimed to compare attending physicians' simulated central venous catheterinsertion performance to published competency standards.

DESIGN

Prospective cohort study of attending physicians' simulated internal jugular and subclavian central venous catheter insertion skills versus a historical comparison group of residents who participated in simulation training.

SETTING

Fifty-eight Veterans Affairs Medical Centers from February 2014 to December 2014 during a 2-day simulation-based education curriculum and two academic medical centers in Chicago.

SUBJECTS

A total of 108 experienced attending physicians and 143 internal medicine and emergency medicine residents.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Using a previously published central venous catheter insertion skills checklist, we compared Veterans Affairs Medical Centers attending physicians' simulated central venous catheter insertion performance to the same simulated performance by internal medicine and emergency medicine residents from two academic centers. Attending physician performance was compared to residents' baseline and posttest (after simulation training) performance. Minimum passing scores were set previously by an expert panel. Attending physicians performed higher on the internal jugular (median, 75.86% items correct; interquartile range, 68.97-86.21) and subclavian (median, 83.00%; interquartile range, 59.00-86.21) assessments compared to residents' internal jugular (median, 37.04% items correct; interquartile range, 22.22-68.97) and subclavian (median, 33.33%; interquartile range, 0.00-70.37; both p < 0.001) baseline assessments. Overall simulated performance was poor because only 12 of 67 attending physicians (17.9%) met or exceeded the minimum passing score for internal jugular central venous catheter insertion and only 11 of 47 (23.4%) met or exceeded the minimum passing score for subclavian central venous catheter insertion. Resident posttest performance after simulation training was significantly higher than attending physician performance (internal jugular: median, 96%; interquartile range, 93.10-100.00; subclavian: median, 100%; interquartile range, 96.00-100.00; both p < 0.001).

CONCLUSIONS

This study demonstrates highly variable simulated central venous catheter insertion performance among a national cohort of experienced attending physicians. Hospitals, healthcare systems, and governing bodies should recognize that even experienced physicians require periodic clinical skill assessment and retraining.

Could low Safety Attitudes Questionnaire scores be indicative of an environment where it may be difficult to get new training practices established?

Introduction

Simulation-based, multiprofessional team training (SBMPTT) is used widely in healthcare, with evidence that it can improve clinical outcomes and be associated with a positive safety culture. Our aim was to explore the impact of introducing this type of training to a gynaecological team.

Methods

In this interrupted time-series study, ‘Safety Attitudes Questionnaire’ (SAQ) data was collected both before and after SBMPTT was introduced to a gynaecological team.

Results

Low baseline SAQ scores coincided with difficulty in establishing the training, meaning that at the end of our study period only a small proportion of staff had actually attended a training session. Despite trends towards improvement in scores for safety climate, teamwork climate and job satisfaction, no statistically significant difference was observed. There was however an improved perception of the level of collaboration between nursing staff and doctors after the introduction of training.

Conclusions and Discussion

In this paper we explore a hypothesis that low baseline SAQ scores may highlight that the multiprofessional teams most in need of training work in environments where it is more challenging to implement. There is evidence from other specialties that multiprofessional team training works, now we need to understand how to address the barriers to getting it started. In this paper we suggest how the SAQ could be used as a directive tool for improvement; using the detailed analysis of the local safety culture it provides to both inform future training design and also provide management with an objective marker of progress.