Annemarie Fransen

Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial.

Please cite this paper as: Fransen A, van de Ven J, Merién A, de Wit‐Zuurendonk L, Houterman S, Mol B, Oei S. Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial. BJOG 2012;119:1387–1393.

Simulation-based team training for multi-professional obstetric care teams to improve patient outcome: a multicentre, cluster randomised controlled trial

To investigate whether simulation‐based obstetric team training in a simulation centre improves patient outcome.

The Effect of Multiprofessional Simulation-Based Obstetric Team Training on Patient-Reported Quality of Care: A Pilot Study.

Introduction This study aimed to explore whether multiprofessional simulation-based obstetric team training improves patient-reported quality of care during pregnancy and childbirth. Methods Multiprofessional teams from a large obstetric collaborative network in the Netherlands were trained in teamwork skills using the principles of crew resource management. Patient-reported quality of care was measured with the validated Pregnancy and Childbirth Questionnaire (PCQ) at 6 weeks postpartum. Before the training, 76 postpartum women (sample I) completed the questionnaire 6 weeks postpartum. Three months after the training, another sample of 68 postpartum women (sample II) completed the questionnaire. Results In sample II (after the training), the mean (SD) score of 108.9 (10.9) on the PCQ questionnaire was significantly higher than the score of 103.5 (11.6) in sample I (before training) (t = 2.75, P = 0.007). The effect size of the increase in PCQ total score was 0.5. Moreover, the subscales “personal treatment during pregnancy” and “educational information” showed a significant increase after the team training (P < 0.001). Items with the largest increase in mean scores included communication between health care professionals, clear leadership, involvement in planning, and better provision of information. Conclusions Despite the methodological restrictions of a pilot study, the preliminary results indicate that multiprofessional simulation-based obstetric team training seems to improve patient-reported quality of care. The possibility that this improvement relates to the training is supported by the fact that the items with the largest increase are about the principles of crew resource management, used in the training.

The impact of transmural multiprofessional simulation-based obstetric team training on perinatal outcome and quality of care in the Netherlands.

BackgroundPerinatal mortality and morbidity in the Netherlands is relatively high compared to other European countries. Our country has a unique system with an independent primary care providing care to low-risk pregnancies and a secondary/tertiary care responsible for high-risk pregnancies. About 65% of pregnant women in the Netherlands will be referred from primary to secondary care implicating multiple medical handovers. Dutch audits concluded that in the entire obstetric collaborative network process parameters could be improved. Studies have shown that obstetric team training improves perinatal outcome and that simulation-based obstetric team training implementing crew resource management (CRM) improves team performance. In addition, deliberate practice (DP) improves medical skills. The aim of this study is to analyse whether transmural multiprofessional simulation-based obstetric team training improves perinatal outcome.Methods/DesignThe study will be implemented in the south-eastern part of the Netherlands with an annual delivery rate of over 9,000. In this area secondary care is provided by four hospitals. Each hospital with referring primary care practices will form a cluster (study group). Within each cluster, teams will be formed of different care providers representing the obstetric collaborative network. CRM and elements of DP will be implemented in the training. To analyse the quality of care as perceived by patients, the Pregnancy and Childbirth Questionnaire (PCQ) will be used. Furthermore, self-reported collaboration between care providers will be assessed. Team performance will be measured by the Clinical Teamwork Scale (CTS). We employ a stepped-wedge trial design with a sequential roll-out of the trainings for the different study groups.Primary outcome will be perinatal mortality and/or admission to a NICU. Secondary outcome will be team performance, quality of care as perceived by patients, and collaboration among care providers.ConclusionThe effect of transmural multiprofessional simulation-based obstetric team training on perinatal outcome has never been studied. We hypothesise that this training will improve perinatal outcome, team performance, and quality of care as perceived by patients and care providers.Trial registrationThe Netherlands National Trial Register, http://www.trialregister.nl/NTR4576, registered June 1, 2014

Cost-effectiveness of simulation-based team training in obstetric emergencies (TOSTI study)

OBJECTIVE Team training is frequently applied in obstetrics. We aimed to evaluate the cost-effectiveness of obstetric multi-professional team training in a medical simulation centre. STUDY DESIGN We performed a model-based cost-effectiveness analysis to evaluate four strategies for obstetric team training from a hospital perspective (no training, training without on-site repetition and training with 6 month or 3-6-9 month repetition). Data were retrieved from the TOSTI study, a randomised controlled trial evaluating team training in a medical simulation centre. We calculated the incremental cost-effectiveness ratio (ICER), which represent the costs to prevent the adverse outcome, here (1) the composite outcome of obstetric complications and (2) specifically neonatal trauma due to shoulder dystocia. RESULTS Mean costs of a one-day multi-professional team training in a medical simulation centre were €25,546 to train all personnel of one hospital. A single training in a medical simulation centre was less effective and more costly compared to strategies that included repetition training. Compared to no training, the ICERs to prevent a composite outcome of obstetric complications were €3432 for a single repetition training course on-site six months after the initial training and €5115 for a three monthly repetition training course on-site after the initial training during one year. When we considered neonatal trauma due to shoulder dystocia, a three monthly repetition training course on-site after the initial training had an ICER of €22,878. CONCLUSION Multi-professional team training in a medical simulation centre is cost-effective in a scenario where repetition training sessions are performed on-site.

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

This is the protocol for a review and there is no abstract. The objectives are as follows: The aim of the review is to evaluate whether simulation-based, multi-professional, obstetric team training results in change on the different levels of training evaluation. Change - in educational and real settings - of health workers performance (e.g. learning experience, knowledge, skills and team performance) and, especially, the impact on maternal and neonatal outcomes will be discussed.

Risk factors of incomplete apgar score and umbilical cord blood gas analysis : a retrospective observational study

Abstract Objective: To investigate whether incomplete umbilical cord blood gas (UCBG) analysis occurs more often than the incomplete reporting of the Apgar score, and risk factors associated with the incomplete values. Methods: A total of 8824 infants born alive after 26 weeks’ gestation between January 2009 and April 2013 were included. We extracted data on five-minute Apgar score, UCBG analysis, gestational age, mode of delivery, time of delivery and multiple pregnancy. Univariate and multivariable logistic regression analyses were performed. Results: Five-minute Apgar score was incomplete in 15 cases (0.2%) and UCBG analysis in 1960 cases (22.2%), p < 0.05. Incomplete UCBG analysis was significantly more likely to occur in situations with Apgar score below seven (Odds ratio (OR) 1.68, 95% CI;1.29-2.19), gestational age between 26 to 27 6/7 and 28 to 31 6/7 weeks (OR 3.14, 95% CI; 2.13-4.62 and OR 1.91, 95% CI; 1.57-2.32), cesarean section (OR 1.31, 95% CI; 1.11-1.55), and multiple pregnancy (OR 2.02, 95% CI; 1.69-2.43). Deliveries during night time had a lower risk of incomplete UCBG analysis (OR 0.78, 95% CI; 0.69-0.88). Conclusions: Measuring five-minute Apgar score generated less incomplete data compared with UCBG analysis. The risk factors associated with incomplete UCBG analysis were noted. Study outcomes with UCBG analysis as neonatal assessment tool should be interpreted with caution.

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.

Board 334 - Research Abstract The Effect of Obstetric Team Training on Perinatal and Maternal Outcome: A Large Multicenter Randomized Controlled Tria (Submission #1092)

Introduction/Background Inquiries have shown that leading causes of substandard care are poor communication and dysfunctional medical teams. In an earlier study we have shown that a one day obstetric team training course improves behavior of professionals six months after the training during unannounced simulated obstetric emergency situations (level 3 Kirkpatrick).1 The question which remains is whether training of healthcare professionals really does improve patient outcome? (level 4 Kirkpatrick). The research question of this study is: Does a one day training of multi-professional obstetric teams in crew resource management (CRM) and medicals skills in a simulation center reduce perinatal and maternal morbidity.2 Methods The obstetric departments of 24 Dutch hospitals were randomly allocated to a one day, multi-professional team training in a medical simulation center or to no such training. The training was mandatory for all employed staff, including gynecologists, residents, midwives and nurses. Team training was given with high-ﬠdelity manikins and facilitated by a communication expert and an obstetrician. Scenarios were not repeated. Eighty percent of time was spent to CRM training and 20% to training of medical skills. For comparison of patient outcome between training and non-training group, data about five maternal and perinatal complications were prospectively collected (primary outcome: perinatal asphyxia, trauma due to shoulder dystocia, eclampsia, severe postpartum hemorrhage and hypoxic-ischemic encephalopathy (HIE)). Data collection was verified with the Dutch Perinatal Registry. For a baseline measurement of these complications, a retrospective search in all hospitals was done. Secondary outcome measures consist of: maternal and perinatal mortality. A Chi-squared test for statistical analysis was used. Results Obstetric departments from 12 hospitals underwent teamwork training. In total 74 gynecologists, 36 residents, 79 midwives and 282 nurses were trained. Overall evaluation by the trainees of the training was 8.7 (scale 0 to 10). During the follow-up period 30,705 children were born in the participating hospitals, 15,991 in the intervention and 14,714 in the control group. The primary outcome measure (consisting of the combination of five maternal and perinatal outcomes) was not significantly different between the intervention and the control group (RR 0.89 (95% CI 0.77-1.02); p 0.093). However, the analysis of the separate maternal and perinatal outcomes showed a significant lower number of trauma due to shoulder dystocia in the intervention group compared to the control group (RR 0.60 (95% CI 0.36-0.997); p 0.046). This same significant effect was seen in the intervention group before and after training (RR 0.53 (95% CI 0.33-0.87); p 0.011). Although there was no significant difference in perinatal mortality between the intervention and control group, there was a trend towards lower perinatal mortalitity in the intervention group versus the control group (RR 0.78 (95% CI 0.57-1.07); p 0.12). The same trend was found before and after training in the intervention group (RR 0.78 (95% CI 0.58-1.06); p 0.118). There was a significant difference in neonatal mortality between the intervention and control group (RR 0.48 (95% CI 0.23-0.999); p 0.045), however this difference was not found over time (RR 1.4 (95% CI 0.54-3.4); p 0.493). Conclusion The obstetric team training did not improve the combined maternal and perinatal outcome. There was no effect on maternal outcome, however there was an effect on perinatal outcome. Trauma due to shoulder dystocia and neonatal mortality decreased significantly (reduction 40 to 50%) in the hospitals that received the simulation training with a not significant trend towards lower perinatal mortality (reduction 22%). However, the decrease in neonatal mortality was not seen over time. This one day obstetric simulation-based team training seems to have a positive translational effect on perinatal outcome but not on maternal outcome. The limited effect might be due to lack of repetition (Ericcson).3,4 References 1. Fransen AF, Van de Ven J, Merién AE, de Wit-Zuurendonk LD, Houterman S, Mol BW, Oei SG. Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial. BJOG 2012;119:1387–93. 2. van de Ven J, Houterman S, Steinweg RA, Scherpbier AJ, Wijers W, Mol BW, Oei SG; TOSTI-Trial Group. Reducing errors in health care: cost-effectiveness of multidisciplinary team training in obstetric emergencies (TOSTI study); a randomised controlled trial. BMC Pregnancy Childbirth. 2010:8;10:59. 3. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100:363–406. 4. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better Results than traditional clinical education? A meta-analytic comparative review of the evidence. Academic Medicine 2011;86:706–11. Disclosures None.

Comparison of the psychological and physiological effects on students of a video-assisted or text introduction to a simulated task

Introduction The use of different methods for introducing the scenario in simulation-based medical education has not been investigated before and may be a useful element to optimise the effectiveness of learning. The aim of this study was to compare an immersive video-assisted introduction to a minimal text-based one, with regard to emotional assessment of the situation. Methods In this pilot study, 39 students participated in a medical simulated scenario. The students were randomly assigned to an experimental group (video-assisted introduction) or a control group (minimal textual introduction) and both were followed by performing surgery on LapSim (Surgical Science, Gothenburg, Sweden). The emotional assessment of the situation, cognitive appraisal, was defined as the ratio of the demands placed by an individual’s environment (primary appraisal) to that person’s resources to meet the demands (secondary appraisal). Secondary outcomes were anxiety (State-Trait Anxiety Inventory), physiological parameters (heart rate, heart rate variability, skin conductance, salivary cortisol), engagement (Game Engagement Questionnaire), motivation (Intrinsic Motivation Inventory) and performance (mean score in percentage calculated by LapSim of predefined levels). Results Participants in the immersive video group (n=17) were overloaded in terms of their perceived demands (a ratio of 1.17, IQR 0.30) compared with those in the control group (a ratio of 1.00, IQR 0.42, n=22) (P=0.01). No significant differences were found between the groups in secondary outcomes. Both groups showed an increase of anxiety after the introduction method. In the experimental group, this score increased from 9.0 to 11.0, and in the textual group from 7.5 to 10.5, both P<0.01. Discussion This study shows that the method of introducing a simulated scenario may influence the emotional assessment of the situation. It may be possible to make your simulation introduction too immersive or stimulating, which may interfere with learning. Further research will be necessary to investigate the impact and usefulness of these findings on learning in simulation-based medical education.