Penny Greenberg

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery. METHODS: A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures. RESULTS: A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (–5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03). CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00381056 LEVEL OF EVIDENCE: I

Assessing Quality in Obstetrical Care: Development of Standardized Measures

BACKGROUND No nationally accepted set of quality indicators exists in obstetrics. A set of 10 outcome measures and three quality improvement tools was developed as part of a study evaluating the effects of teamwork on obstetric care in 15 institutions and > 28,000 patients. Each outcome was assigned a severity weighting score. MEASURES Three new obstetrical quality improvement outcome tools were developed. The Adverse Outcome Index (AOI) is the percent of deliveries with one or more adverse events. The average AOI during the pre-implementation data collection period of the teamwork study was 9.2% (range, 5.9%-16.6%). The Weighted Adverse Outcome Score (WAOS) describes the adverse event score per delivery. It is the sum of the points assigned to cases with adverse outcomes divided by the number of deliveries. The average WAOS for the preimplementation period was 3 points (range, 1.0-6.0). The Severity Index (SI) describes the severity of the outcomes. It is the sum of the adverse outcome scores divided by the number of deliveries with an identified adverse outcome. The average SI for the pre-implementation period was 31 points (range, 16-49). DISCUSSION The outcome measures and the AOI, WAOS, and SI can be used to benchmark ongoing care within and among organizations. These tools may be useful nationally for determining quality obstetric care.

Effects of teamwork training on adverse outcomes and process of care in labor and delivery : A randomized controlled trial

ABSTRACT Reports from the Institute of Medicine propose that team training—and implementing team behaviors—can cut down on medical errors and enhance patient safety. The present investigators tested this idea in the area of obstetrics, a discipline that calls for intensive and error-free vigilance as well as effective communication between numerous disciplines. A cluster-randomized controlled trial was undertaken at 15 US hospitals: at seven a standardized teamwork training curriculum was introduced that focused on free communication and team structure. The remaining eight hospitals made up a control group. The curriculum (MedTeams Labor and Delivery Team Coordination Course) was based on care resource management, which attempts to utilize the ability of each team member to analyze and react to situations in ways that lessen the potential for error. A total of 1307 individuals were trained, and 28,536 deliveries were analyzed. Negative outcomes were quantified using an index outcome measure, the Adverse Outcome Index. The intervention and control groups were similar demographically and obstetrically at the outset. Adverse outcome indices also were comparable, and remained so after teamwork training was implemented. The only process measure that differed significantly after team training was in the interval from deciding to perform an immediate cesarean delivery to making the incision, which decreased from 33 to 21 minutes. There was considerable variability across hospitals in the commonest maternal outcome, a third- or fourth-degree perineal laceration following vaginal delivery, and also in the most prevalent neonatal outcome, unplanned admission to the neonatal intensive care unit. Postimplementation outcome measures did not differ significantly even after controlling for baseline differences. This study failed to show that teamwork training in obstetrical practices had any important clinical impact. Nevertheless, the Adverse Outcome Index might prove helpful when comparing obstetrical outcomes within and between institutions.