Colleen Lee

Simulation as a tool for improving acquisition of neonatal resuscitation skills for obstetric residents

Abstract Objective: Our goal was to compare the confidence, knowledge, and performance of obstetric residents taught initial neonatal resuscitation steps in a simulation-based versus lecture-based format. Methods: Our study was a prospective randomized controlled trial of 33 obstetric residents. Baseline confidence, knowledge, and clinical skills assessments were performed. Subjects were randomized to traditional lecture (n = 14) or simulation-based (n = 19) neonatal resuscitation curriculum with a focus on initial steps. Follow-up assessments were performed at 3 and 6 months. Total confidence, knowledge, and clinical performance scores and change from baseline in these scores were calculated and compared between groups. Results: Both the lecture-based and simulated-based groups demonstrated significant improvement in confidence, knowledge, and performance over time. However, compared with the lecture group, the magnitude of the mean change from baseline in performance scores was significantly greater in the simulation group at 3 months (2.9 versus 10.1; p < 0.001), but not at 6 months (7.0 versus 9.3; p = 0.11). Conclusions: Our study demonstrates the superiority of simulation in teaching obstetric residents initial neonatal resuscitation steps compared with a traditional lecture format. Skills are retained for upwards of 3–6 months. Refresher instruction by 6 months post-instruction may be beneficial.

Validating Obstetric Emergency Checklists using Simulation: A Randomized Controlled Trial

Background The World Health Organizations Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.

Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist

Objective Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgency of the case; and decrease documentation discrepancies among nursing, obstetric, anesthesia, and pediatric staff. Methods Retrospective review of 600 CDs on our 2 labor and delivery suites before and after the introduction of 2 consecutive versions of our obstetric safe surgery checklist (100 cases in each cohort) was undertaken. The first version was released in 2010, and after modifications based on initial findings, our current version was released in 2014. One hundred consecutive CDs were identified from each of the 3 periods at each hospital, and charts for those patients and newborns were abstracted. Notes by obstetricians, nurses, anesthesiologists, and pediatricians were reviewed. We compared the rates of agreement in the documentation of the indication for the CD between the different members of the team. Chi-square analyses were performed. Results Complete agreement among the 4 specialties in the documented indication for CD before introduction of our initial safe surgery checklist was noted in 59% (n = 118) of cases. After initial checklist introduction, agreement decreased to 43% (n = 86; P = 0.002). We then modified our checklist to include indication for CD and level of urgency and changed our policy to include pediatric staff participation in the timeout. Agreement in a subsequent chart review increased to 80% (n = 160), significantly better than in our initial analysis (P < 0.001) and our interim review (P < 0.001). The greatest improvement in agreement was observed between obstetricians and pediatricians. Conclusions Implementation of a safe surgery checklist can improve communication at CDs, but care should be taken when implementing checklists because they can have unanticipated consequences. Ongoing review and modification are critical to ensure safer medical care.

Shoulder Dystocia: Quality, Safety, and Risk Management Considerations.

Shoulder dystocia is a term that evokes terror and fear among many physicians, midwives, and health care providers as they recollect at least 1 episode of shoulder dystocia in their careers. Shoulder dystocia can result in significant maternal and neonatal complications. Because shoulder dystocia is an urgent, unanticipated, and uncommon event with potentially catastrophic consequences, all practitioners and health care teams must be well-trained to manage this obstetric emergency. Preparation for shoulder dystocia in a systematic way, through standardization of process, practicing team-training and communication, along with technical skills, through simulation education and ongoing quality improvement initiatives will result in improved outcomes.

Second Victim Experiences in Obstetrics and Gynecology [339].

OBJECTIVE: To evaluate the “second victim” experiences of health care providers at our institution to guide development of a comprehensive system to better support them. METHODS: Anonymous electronic surveys were distributed to physicians to assess knowledge of the second victim concept, stages of recovery, and to elicit personal experiences. Descriptive data are presented. RESULTS: Of 175 physicians invited, 85 (49%) completed the survey. Physicians were at various levels of training (51% trainees, 49% attendings), were primarily female (77.6%), and represented a wide variety of ages. More than one third (36%) were not aware of the concept, and only 11% were familiar with described stages of recovery. Forty-one of 85 respondents (48%) reported their most significant unanticipated adverse patient event, medical error, or patient-related injury occurred in the last 6 months (64% obstetric, 36% gynecologic). Seventy-two percent of respondents felt they were in the moving on: thriving stage; however, 28% of our health care providers remain in various other stages of recovery, including intrusive reflections, restoring personal integrity, enduring the inquisition, and moving on (surviving). The most helpful support reported by respondents was peers (66%), whereas the greatest barrier to obtaining support was available time (40%). Physicians desired the following to facilitate recovery: safe and confidential space for discussion, someone to check in on their well-being, and information about what to expect. CONCLUSION: Development of an organized support system is something that physicians at our institution feel would help after involvement in an adverse medical event. Training peers to counsel their colleagues about how to provide support after an event with frequent check-ins within a safe, confidential setting may help facilitate health care provider recovery.

Board 314 - Research Abstract Simulation as a Tool for Improving Acquisition of Neonatal Resuscitation Skills (Submission #946)

Introduction/Background The first few minutes after birth are most critical for a newborn. Although most infants transition with ease, some require delivery room resuscitation.1 The quality of initial resuscitation may impact the infant’s short- and long-term outcome.2 Traditionally, neonatal providers are present at deliveries as soon as the need is recognized and delivery of the infant is imminent. However, in the event that the neonatal resuscitation team is not present, the obstetric team must initiate resuscitation. While obstetric nurses complete resuscitation training, obstetric physicians are often not required to complete neonatal resuscitation training. In order to fulfill this educational need we hypothesize that a short instructional session that teaches initial neonatal resuscitation steps with a simulation based curriculum will increase obstetric physician confidence, knowledge, performance and retention of neonatal resuscitation skills. Methods This was a prospective randomized, controlled trial of 33 obstetric residents. Subjects received baseline confidence, knowledge and clinical skills assessments. Subjects were then randomized to traditional lecture (n=14) or simulation-based (n=19) neonatal resuscitation education with a focus on initial steps. All instructional sessions were less than one hour in duration and both lecture and simulation interventions contained the same content. The simulation session required that the subject learn how to resuscitate a depressed neonate “hands on” with expert coaching. Follow-up assessments of confidence, knowledge and clinical skills occurred at intervals of three and six months post initial instruction. Confidence was reported based on a Likert scale of 1 (least confident) to 5 (most confident). Knowledge was assessed using seven multiple choice questions at the three intervals. Clinical assessments were performed in a simulated environment and were graded as yes/no if the subject completed individual tasks successfully in the following areas: preparation, initial resuscitation, ventilation, cardiovascular resuscitation. Total knowledge and clinical assessment scores were calculated. Statistical analysis was performed with paired T-tests to test individuals improvement and Student T-test for comparisons between groups. Results For both the lecture and simulation-based groups, confidence increased significantly at three and six months post instruction when compared to baseline (p<0.01). This increase in confidence was sustained as there were no significant differences between confidence at three and six months in both groups. Performance on knowledge assessment questions also improved significantly from baseline at three and six months post instruction for both groups when compared to baseline (p<0.01). Knowledge was maintained as there were no significant differences between knowledge scores at three and six months in both groups. Clinical assessments for the lecture group revealed no significant difference in successfully completed tasks between baseline and three months. However, significant improvement was demonstrated when six month performance was compared to baseline and 3 months (P<0.01). For the simulation group, clinical assessment performance was significantly improved at three and six months versus baseline (p<0.01) and this improvement was sustained with no significant difference between three and six month scores. Although there was an overall improvement in both groups, analysis with Student T-tests demonstrated that simulation performance scores were significantly higher than the lecture group at both three months (19.8 vs. 13.4) (p<0.01) and 6 months (19.1 vs. 17.2) (p<0.05). Conclusion A short, focused curriculum that teaches initial neonatal resuscitation steps via lecture or simulation enhances subject confidence, knowledge and skills. However, education that incorporates simulation is superior to lecture, resulting in more rapid acquisition of clinical skills and sustained improvements in overall clinical performance. Fortunately, an unanticipated depressed neonate is a relatively infrequent event; however, improved ability for obstetric providers to initiate a prompt and effective neonatal resuscitation after a brief simulation intervention, has the potential to greatly impact outcomes for these vulnerable newborns. References 1. Perlman JM, Risser R: Cardiopulmonary resuscitation in the delivery room: associated clinical events. Arch Pediatr Adolesc Med 1995; 149:20-25. 2. Casalaz DM, Marlow N, Speidel BD: Outcome of resuscitation following unexpected apparent stillbirth. Arch Dis Child Fetal Neonatal Ed 1998;78:F112-F115. Disclosures None.

Using a prenatal electronic medical record to improve documentation within an inner-city healthcare network.

OBJECTIVE To study the impact of a prenatal electronic medical record (EMR) on the adequacy of documentation. STUDY DESIGN The authors reviewed paper prenatal records (historical control arm and contemporaneous control arm), and prenatal EMRs (study arm). A prenatal quality index (PQI) was developed to assess adequacy of documentation; the prenatal record was assigned a score (range, -1 to 2 for each element, maximum score = 30). A PQI raw score and PQI ratio-that controlled for which elements of care were indicated for a patient-were calculated and compared between the study arm versus historical control arm and then the study arm versus contemporaneous control arm. RESULTS The median PQI raw score was significantly lower in the study arm compared with historical control arm; however, the PQI ratios were similar between these groups. The PQI raw score was similar in both the study arm and contemporaneous control arm; however the PQI ratio was significantly higher in the study arm when compared with the contemporaneous control arm. CONCLUSION Implementation of this prenatal EMR did not have a significant impact on completeness of documentation when compared with a standardized paper prenatal record. Adequacy of documentation seems to be related to the type of practice.