Julie Arafeh

Debriefing in simulated-based learning: facilitating a reflective discussion.

The topic of debriefing has received little attention in the simulation literature. In simulation, knowing how to debrief the learners experiences is as essential as creating scenarios and selecting the correct manikin. The purpose of this article will be to discuss debriefing as it relates to simulation-based learning. Aspects of simulation-based learning, including briefing (preparing learners for simulation) and the simulation (scenario), will be reviewed because they have particular relevance to debriefing. Guidelines and strategies for debriefing will be discussed to facilitate the learners ability to reflect on their performance. Debriefing will be reviewed following 3 occasions: a critical patient event, an in situ drill, and a simulation at a simulation center. Since debriefing may be different in each of these instances, customizing debriefing to fit the learning environment will be examined. Finally, because of the significance of debriefing on learning, evaluation of the debriefer will be addressed to ensure optimal performance.

Prospective randomized trial of simulation versus didactic teaching for obstetrical emergencies.

Introduction: The objective of this study was to determine whether simulation was more effective than traditional didactic instruction to train crisis management skills to labor and delivery teams. Methods: Participants were nurses and obstetric residents (<5 years experience). Both groups were taught management for shoulder dystocia and eclampsia. The simulation group received 3 hours of training in a simulation laboratory, the didactic group received 3 hours of lectures/video and hands-on demonstration. Subjects completed a multiple-choice questionnaire before training and before testing. After 1 month, all teams underwent performance testing as a labor and delivery drill. All drills were video recorded. Team performances were scored by a blinded reviewer using the video recordings and an expert-developed checklist. The data were analyzed using independent samples Student t test and analysis of variance (one way). P value of ≤0.05 was considered to be statistically significant. Results: There was no statistical difference found between the groups on the pretraining and pretesting multiple-choice questionnaire scores. Performance testing performed as a labor and delivery drill showed statistically significant higher scores for the simulation-trained group for both shoulder dystocia (Sim = 11.75, Did = 6.88, P = 0.002) and eclampsia management (Sim = 13.25, Did = 11.38, P = 0.032). Conclusions: In an academic training program, didactic and simulation-trained groups showed equal results on written test scores. Simulation-trained teams had superior performance scores when tested in a labor and delivery drill. Simulation should be used to enhance obstetrical emergency training in resident education.

Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises.

OBJECTIVE Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance. STUDY DESIGN We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions. RESULTS Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines. CONCLUSION Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.

The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy

This consensus statement was commissioned in 2012 by the Board of Directors of the Society for Obstetric Anesthesia and Perinatology to improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest. The recommendations in this statement were designed to address the challenges of an actual event by emphasizing health care provider education, behavioral/communication strategies, latent systems errors, and periodic testing of performance. This statement also expands on, interprets, and discusses controversial aspects of material covered in the American Heart Association 2010 guidelines.

Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association.

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

Use of simulation based team training for obstetric crises in resident education.

Background: Obstetric crises are unexpected and random. Traditionally, medical training for these acute events has included lectures combined with arbitrary clinical experiences. This educational paradigm has inherent limitations. During actual crises insufficient time exists for discussion and analysis of patient care. Our objective was to create a simulation program to fill this experiential gap. Methods: Ten L&D teams participated in high fidelity simulation training. A team consisted of two or three nurses, one anesthesia resident and one or two obstetric residents. Each team participated in two scenarios; epidural-induced hypotension followed by an amniotic fluid embolism. Each simulation was followed by a facilitated debriefing. All simulations were videotaped. Clinical performances of the obstetric residents were graded by two reviewers using the videotapes and a faculty-developed checklist. Recurrent errors were analyzed and graded using Health Failure Modes Effects Analysis. All team members completed a course evaluation. Results: Performance deficiencies of the obstetric residents were identified by an expert team of reviewers. From this list of errors, the “most valuable lessons” requiring further focused teaching were identified and included 1) Poor communication with the pediatric team, 2) Not assuming a leadership role during the code, 3) Poor distribution of workload, and 4) Lack of proper use of low/outlet forceps. Participants reported the simulation course allowed them to learn new skills needed by teams during a crisis. Conclusion: Simulated obstetric crises training offers the opportunity for educators to identify specific performance deficits of their residents and the subsequent development of teaching modules to address these weaknesses.

The Case for OBLS: A Simulation-based Obstetric Life Support Program

Errors by health care professionals result in significant patient morbidity and mortality, and the labor and delivery ward is one of the highest risk areas in the hospital. Parturients today are of higher acuity than anytime previously, and maternal mortality is increasing. Obstetrical staff must therefore be familiar with emergency protocols geared to the maternal-fetal dyad. However, the medical literature suggests that obstetrical providers are not optimally trained to render care during maternal cardiopulmonary arrest. We describe the evolution of immersive learning and simulation in the Neonatal Resuscitation Program, and suggest the development of a multidisciplinary team, simulation-enhanced obstetric crisis training program (OBLS) may likewise benefit obstetrical health care professionals. OBLS would emphasize high quality basic life support, uterine displacement, use of an automatic external defibrillator, and delivery of the fetus within 5 minutes of maternal arrest should resuscitative efforts prove ineffective.

Nursing department orientation: are we missing the mark?

Hospitals routinely provide orientation for the new nurses they hire. The evolution of nursing practice is not reflected in the current teaching methods of nursing orientation. The authors examine the past 60 years of nursing department orientation and assert the need to move toward more effective and innovative teaching strategies.

Simulation-based training: the future of competency?

Traditionally, continuing education has focused on cognitive skills and technical skills, namely, what the provider needs to know and what the provider needs to be able to do. Successful completion of such education programs has conferred some degree of competence on the learner. For the most part, continuing education has been performed in silos with each healthcare provider discipline developing a program designed to meet the needs of their group. The Institute of Medicine and the Joint Commission have issued reports addressing patient safety, morbidity, and mortality of the newborn infant and maternal mortality, respectively. These reports call for the education of healthcare providers to include multidisciplinary team training and/or drills. Simulation-based training (SBT) is a methodology of education that is uniquely able to address cognitive and technical skills as well as behavioral skills and is ideal for multidisciplinary team training. As a result, SBT is beginning to be adopted in healthcare education. However, the following questions remain: Is a dedicated simulation space necessary, how should SBT be incorporated into the existing education program, and will it confer competency?

Implementing and Sustaining In Situ Drills to Improve Multidisciplinary Health Care Training

In situ drills are a key adjunct to evidence-based protocols and established educational programs. Well-planned and conducted drills can further reinforce important educational concepts concerning high-risk events such as maternal hemorrhage, allow the team to develop skills to improve performance, and uncover systems errors. Evaluation of the findings from the drills and topics discussed during debriefing can lead to optimized training and refinement of the patient care setting to support an optimal environment for patient care and safety.