Stephen D. Pratt

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.

An association between severe labor pain and cesarean delivery.

The relationship between epidural analgesia and cesarean delivery remains controversial. Several studies have documented an association, although others have not. This inconsistency may result from an association between severe labor pain and dystocia. We hypothesized that dystocia causes severe labor pain, such that more epidural medication is required to maintain comfort. We examined the relationship between labor outcome and severe pain, defined by the number of supplemental epidural boluses. We retrospectively reviewed the anesthesia records of 4493 parturients who received small-dose labor epidural analgesia. An independent association was found between operative delivery and maternal age, body mass index, nulliparity, fetal weight, induction of labor, and the number of boluses required during labor. By using multivariate analysis, the odds ratio of cesarean delivery among women who required at least three boluses was 2.3 compared with those who required two boluses or less. No association was found between the concentration of bupivacaine in the epidural infusion and operative delivery. Because women with cesarean deliveries appeared to have more pain, degree of labor pain may be a confounding factor in studies examining epidural analgesia and outcome. Implications: This is a retrospective observational study demonstrating an association between labor pain and cesarean delivery. Our results provide an alternative explanation of why epidural analgesia is associated with cesarean delivery.

Simulation in Obstetric Anesthesia

Simulation can be used to teach technical skills, to evaluate clinician performance, to help assess the safety of the environment of care, and to improve teamwork. Each of these has been successfully demonstrated in obstetric anesthesia simulation. Task simulators for epidural placement, failed intubation, and blood loss estimation seem to improve performance. Resident performance in an emergency cesarean delivery can be measured and assessed against his/her peers. Running simulated crises on a labor and delivery unit (in situ drills) can help to identify and correct potential safety concerns (latent errors) without exposing patients to the risks associated with these concerns. Finally, simulation can effectively assess and teach teamwork tools and behaviors. It is unclear, however, how well the lessons learned in the simulated environment translate into improved behaviors or better care in the clinical setting, or whether simulation improves patient outcomes. More research is needed to help answer these questions.

Low dose intrathecal ropivacaine with or without sufentanil provides effective analgesia and does not impair motor strength during labour: a pilot study.

PurposeAlthough ropivacaine has been used to provide spinal anesthesia in the surgical population, its intrathecal administration for labour analgesia has only recently been described. We evaluated the effects of low dose intrathecal ropivacaine with or without sufentanil for labour analgesia.MethodsThirty-six term parturients in active labour were randomly assigned to receive 3 mg of intrathecal ropivacaine (group R) or 3 mg ropivacaine with 10 μg of sufentanil (group RS). Patients were evaluated by a blinded observer for hypotension, linear analogue score (VAS 0–100) for labour pain, motor power in the lower limbs, onset of analgesia, sensation to cold and pin prick, duration of analgesia, and neonatal Apgar scores. The following day patients were assessed for satisfaction, headache and neurologic deficit.ResultsThe mean duration of analgesia in the R group was 41.4 ± 4.9 min and 95.0 ± 6.1 min in the RS group (mean ± SEM, P=0.0001). All subjects had satisfactory analgesia at five minutes, although analgesia from the ropivacaine-sufentanil combination was superior to that provided by ropivacaine alone. Total duration of labour was no different between the groups (R-306 ± 34, RS-384 ± 44 min, P=0.17). No patient showed evidence of motor block. All patients were satisfied with the labour analgesia. No neurological complications were observed.ConclusionsLow dose ropivacaine provides effective analgesia during labour via the intrathecal route. It can be mixed with sufentanil in the above-mentioned concentrations to improve both the quality and duration of analgesia. Fetal outcome remains favourable. It may provide minimal or no motor block, to facilitate ambulation.RésuméObjectifMême si la ropivacaïne a été utilisée pour la rachianesthésie chirurgicale, son administration intrathêcale comme analgésie pendant le travail n’a été étudiée que récemment. Nous avons évalué les effets d’une faible dose de ropivacaïne intrathêcale avec ou sans sufentanil comme analgésie pendant le travail.MéthodeTrente-six parturientes à terme, en travail actif, ont été réparties au hasard et ont reçu 3 mg de ropivacaïne intrathêcale (groupe R) ou 3 mg de ropivacaïne avec 10 mg de sufentanil (groupe RS). Un observateur objectif a évalué l’hypotension, la douleur du travail selon une échelle visuelle analogique (EVA, 0–100), la force motrice des membres inférieurs, le début de l’analgésie, la sensation de froid, la sensibilité à la piqûre, la durée de l’analgésie chez la mère et l’indice d’Apgar chez le nouveau-né. Le jour suivant l’accouchement, on a noté la satisfaction des patientes, la présence de céphalées et de déficit neurologique.RésultatsLa durée moyenne de l’analgésie a été, dans le groupe R, de 41,4 ± 4,9 min et, dans le groupe RS, de 95,0 ± 6,1 min (moyenne ± erreur type), P = 0,0001). Toutes les patientes étaient satisfaites de l’analgésie à cinq minutes, quoique l’analgésie fournie par la combinaison de ropivacaïne-sufentanil ait été supérieure à l’analgésie fournie par la ropivacaïne seule. La durée totale du travail n’a pas présenté de différence intergroupe (R-306 ± 34, RS- 384 ± 44 min, P = 0,17). Aucune patiente n’a présenté d’évidence de bloc moteur. Toutes les patientes ont été satisfaites de l’analgésie pendant le travail. Aucune complication neurologique n’est survenue.ConclusionL’administration intrathécale d’une faible dose de ropivacaïne fournit une analgésie efficace pendant le travail. Elle peut être combinée au sufentanil selon les concentrations susmentionnées afin d’améliorer la qualité et la durée de l’analgésie. L’évolution du bébé demeure favorable. La ropivacaïne peut entraîner un blocage moteur minimal, ou l’absence de bloc, ce qui permet à la patiente de déambuler.

How to develop a second victim support program: a toolkit for health care organizations.

A toolkit was developed to help health care organizations implement support programs for clinicians suffering from the emotional impact of errors and adverse events. Based on the best available evidence related to the second victim experience, the toolkit consists of 10 modules, each with a series of specific action steps, references, and exemplars.

Small dose bupivacaine-fentanyl spinal analgesia combined with morphine for labor.

We investigated the duration of labor analgesia produced by a small dose of spinal bupivacaine/fentanyl alone or in combination with a small dose of morphine. Sixty parturients were enrolled in this placebo-controlled, double-blinded, randomized trial. All women received a spinal injection of 12.5 &mgr;g of fentanyl with 2 mg of bupivacaine. The morphine group (MBF) also received 125 &mgr;g of morphine; the placebo group (BF) received saline. Pain scores were <3 of 10 within 10 min of injection. The median duration of analgesia was similar between groups (89 min versus 84 min; P = not significant), and only 20% of the MBF group experienced prolonged analgesia. During subsequent epidural analgesia, the MBF group had a significantly lesser rate of breakthrough pain (0.15 ± 0.14 episodes per hour versus 0.26 ± 0.18 episodes per hour; P = 0.02). Also, during the first 24 h postpartum, the MBF group required significantly fewer medications (3.3 ± 3.7 doses versus 4.7 ± 3.5 doses; P = 0.04). Intrathecal injection of this small dose of bupivacaine/fentanyl produced a rapid onset of labor analgesia; the addition of a small dose of morphine did not significantly prolong analgesia, but it improved subsequent pain relief, as measured by the rate of breakthrough pain and postpartum medication requirements. This may provide a clinically useful means of improving intra- and postpartum pain relief.

Recent trends in simulation for obstetric anesthesia.

PURPOSE OF REVIEW The use of simulation in medicine has grown significantly over the past 2 decades. Simulation in obstetric anesthesia can be divided into four broad uses: technical skills, nontechnical or teamwork skills, individual clinical competence, and the safety of the clinical environment. This review will describe recent trends in the use of simulation in several of these categories. RECENT FINDINGS Simulation continues to be an important part of skills (technical and cognitive) and teamwork training in obstetric anesthesia. The acquisition of simple and complex technical skills appears to be improved with the use of simulation. However, the assessment of these skills is currently done in the simulated environment. Simulation is also important in assessing and enhancing the safety of a labor unit. Two simulation trends have recently evolved. Instructional articles describing how to best perform simulation have begun to appear. In addition, several review articles have been published that demonstrate the maturation of the body of research in this field. SUMMARY As the use of simulation continues to grow, research should concentrate on whether anesthesia or teamwork skills learned in the simulated environment change behavior and improve outcomes in the clinical setting. More instructional publications would also facilitate the growth into more clinical environments.

A novel actuator for simulation of epidural anesthesia and other needle insertion procedures.

Introduction: When navigating a needle from skin to epidural space, a skilled clinician maintains a mental model of the anatomy and uses the various forms of haptic and visual feedback to track the location of the needle tip. Simulating the procedure requires an actuator that can produce the feel of tissue layers even as the needle direction changes from the ideal path. Methods: A new actuator and algorithm architecture simulate forces associated with passing a needle through varying tissue layers. The actuator uses a set of cables to suspend a needle holder. The cables are wound onto spools controlled by brushless motors. An electromagnetic tracker is used to monitor the position of the needle tip. Results: Novice and expert clinicians simulated epidural insertion with the simulator. Preliminary depth-time curves show that the user responds to changes in tissue properties as the needle is advanced. Some discrepancy in clinician response indicates that the feel of the simulator is sensitive to technique, thus perfect tissue property simulation has not been achieved. Conclusions: The new simulator is able to approximately reproduce properties of complex multilayer tissue structures, including fine-scale texture. Methods for improving fidelity of the simulation are identified.

Team Approach to Care in Labor and Delivery

Changing to a teamwork culture in labor and delivery requires a real commitment. The skills involved can be taught to all healthcare providers. The benefits of a teamwork culture may include improved patient outcomes, less medical errors, and improved patient and staff satisfaction. Malpractice claim reduction may possibly occur through these improved outcomes and better communication with our patients.