Andrew Satin

Resident training for eclampsia and magnesium toxicity management: simulation or traditional lecture?

OBJECTIVE To compare eclampsia and magnesium toxicity management among residents randomly assigned to lecture or simulation-based education. STUDY DESIGN Statified by year, residents (n = 38) were randomly assigned to 3 educational intervention groups: Simulation→Lecture, Simulation, and Lecture. Postintervention simulations were performed for all and scored using standardized lists. Maternal, fetal, eclampsia management, and magnesium toxcity scores were assigned. Mann-Whitney U, Wilcoxon rank sum and χ(2) tests were used for analysis. RESULTS Postintervention maternal (16 and 15 vs 12; P < .05) and eclampsia (19 vs 16; P < .05) scores were significantly better in simulation based compared with lecture groups. Postintervention magnesium toxcitiy and fetal scores were not different among groups. Lecture added to simulation did not lead to incremental benefit when eclampsia scores were compared between Simulation→Lecture and Simulation (19 vs 19; P = nonsignificant). CONCLUSION Simulation training is superior to traditional lecture alone for teaching crucial skills for the optimal management of both eclampsia and magnesium toxicity, 2 life-threatening obstetric emergencies.

A Simulation Program for Teaching Obstetrics and Gynecology Residents the Pediatric Gynecology Examination and Procedures

STUDY OBJECTIVE To assess the use of a pelvic simulation curriculum to teach obstetrics and gynecologic residents the pediatric gynecology examination and procedures. DESIGN Residents in obstetrics and gynecology participated in a simulation curriculum using a modified pelvic hemimodel to simulate a pediatric pelvis. PARTICIPANTS 19 obstetrics and gynecology residents completed the study protocol. INTERVENTIONS Digitally recorded encounters with a standardized patient scenario using the simulator were utilized. After the initial encounter the trainees participated in a formal lecture and demonstration using the model. The trainees were then reassessed at least four weeks after the initial encounter; results were reviewed by a blinded evaluator. Scores were analyzed using the two-sided t-test and Wilcoxon signed-rank test. MAIN OUTCOME MEASURES Scores from before to after the simulation training. RESULTS A total of 19 residents completed the study protocol and demonstrated significant improvement in scores from before to after the simulation training. Scores improved from a pre-training mean of 6.1 to post-training mean of 16.7 (P = 0.0001). Improvement was seen at all levels of residency training. Specific skill sets included in the Council for Resident Education in Obstetrics and Gynecology (CREOG) Educational objectives (1) were improved including: pediatric gynecologic examination, collection of microbial cultures, vaginal lavage and vaginoscopy. CONCLUSIONS This teaching program using a simulation model was found to be an effective tool to improve resident knowledge and performance of the skills needed to accomplish the pediatric gynecology examination.

Early Postpartum Glucose Testing in Women with Gestational Diabetes Mellitus.

Objective Given that most women with gestational diabetes mellitus (GDM) never undergo the recommended 6 to 12 weeks postpartum glucose tolerance test (GTT), we assessed the feasibility of performing GTTs on postpartum day 2. Study Design Women with abnormal postpartum day 2 results were similar to women with normal postpartum day 2 results except that more women with abnormal results required medicine to treat their GDM (Table 1). [corrected]. We assessed the feasibility of this GTT and compared the results to the standard of care GTT at 6 to 12 weeks postpartum. We also evaluated maternal and pregnancy characteristics of women who return for 6 to 12 weeks GTTs compared with those lost to follow-up. Results In this study, 98 of 106 participants (92%) completed the postpartum day 2 GTT; 59% had normal glucose values at that time. Only 49 women returned at 6 to 12 weeks postpartum. Among women who had testing at both time points, the 2 days postpartum GTT were 100% sensitive and 94% specific for diabetes mellitus but less sensitive and specific for milder forms of abnormal glucose. Women who did not return for testing at 6 to 12 weeks postpartum were more likely to have less education, have Medicaid, and to have GDM previously (Table 2). [corrected]. Conclusion Performing GTTs on postpartum day 2 is feasible and should be further investigated as an alternative postpartum testing regimen in GDM.

Developing a program, a curriculum, a scenario

Simulation in obstetrics and maternal-fetal medicine is an educational tool that can be employed to address local and national learning objectives for residents and fellows. Simulation may also be incorporated as part of a comprehensive patient safety program to improve maternal and neonatal outcomes. Our objective is to identify steps in designing an effective simulation program, curricula, and scenario using available evidence and drawing on experience. Identification of needs, leadership, and financial and logistic resources is the first step in program design. An appropriate curriculum may be crafted with the intended audience and clear learning objectives in mind. Simulation scenario design is best achieved in a stepwise, layered fashion and must incorporate time for debriefing, feedback, and didactics. Simulation programs of any size, budget, and scope can be successfully implemented at the local, regional, and national levels to enhance education and improve patient safety.

Improving Shoulder Dystocia Management and Outcomes with a Targeted Quality Assurance Program

Background Several investigators have achieved remarkable success in transferring shoulder dystocia management skills mastered with simulation training to clinical practice. However, other investigators have not demonstrated similar benefits, raising questions about the comparative effectiveness of specific simulation schemes, instructional content, and additional quality assurance measures between successful and unsuccessful interventions. After our initial review revealed gaps in following shoulder dystocia management algorithms, documentation and timely follow‐up of injured neonates, we developed and implemented five interventions, three educational and two systems‐level, aimed at improving shoulder dystocia management. Objective To describe the clinical impact of a systematic program of quality improvement on outcomes of vaginal births complicated by shoulder dystocia. Setting An urban tertiary academic medical center that trains 36 obstetrics/gynecology residents (9 per year) and provides comprehensive obstetrical services for approximately 2,000 deliveries annually. Study Design We use SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) to (1) describe our core instructional content and simulation‐based practice, emphasizing specific proscriptive and prescriptive recommendations and their evidence basis, and (2) to report an interrupted time series assessment of the clinical impact of our systematic quality improvement program targeting shoulder dystocia‐associated brachial plexus injury. Results Compared with baseline (June 1993 to December 2004), the incidence of shoulder dystocia among vaginally delivered infants with birth weight ≥ 2,500 g at Johns Hopkins Hospital (January 2014 to December 2015) increased from 2.6 to 4.6% (X2 = 29.8; df = 1; p < 0.0001); in addition, documentation improved, direct fetal manipulation increased, while use of episiotomy for the management of shoulder dystocia decreased. While preintervention only 65% of brachial plexus injury were associated with shoulder dystocia, 100% of neonatal brachial plexus injuries were associated with shoulder dystocia postintervention (80/122 [65%] vs. 7/7 [100%], X2 = 3.66; df = 1; p = 0.055), a trend reflecting simultaneous increased recognition of impacted shoulders and improved overall management of shoulder dystocia. Most importantly, the incidence of brachial plexus injury among shoulder‐dystocia‐complicated vaginal deliveries has decreased from a baseline of 31.6 to 6.3% (X2 = 27.9; df = 1; p < 0.0001), and the absolute brachial plexus injury rate declined from 8.2 to 2.9 per 1,000 vaginal births ≥ 2,500 g, a reduction of 64.5% (X2 = 7.3; df = 1; p = 0.007). Conclusion A systematic program of quality assurance with specific proscriptive and prescriptive instructional content and management recommendations is associated with improved recognition, management, and clinical outcomes of shoulder dystocia.