Simulation in Obstetrics

Dr. Renee BobrowskiDebbie Ketchum, BSN, RNC,

MAOMKelly Wilson, RNC

Getting to Know YOU

• How many of you are actively involved in OB simulation?

• How many of you lead teams for simulation?

• How many of you have been to other conferences regarding this subject?

• How many of you have had to be the OB patient for Simulation?

Objectives

• Why do we do it?• What it simulation? • Clinical value in medicine• How do we do it…

THE

WHY

Why do we need a new training method?

Suburban Hospital Staff #sObstetricians

81

L&D Nurses 50

Anesthesiologists 16

NNPs 12

Scrub Techs 14

CRNAs 35

How many C/S teams are possible with these staff numbers?

381 Million!

The Number One Risk to Safety?

Variability!

What is Medical Simulation• Use of a device or series of devices along

with clinical personnel, – To emulate a real patient care situation or

environment– For the purpose of training and evaluation

• It is not just “technology”– It is a proven “technique” to train healthcare

personnel • without risk to the patient or members of the

clinical team

• Provides the opportunity for clinicians to…– Practice routine as well as low incidence, high risk

events

THE

WHAT

Simulation• Ancient Greeks used to illustrate

philosophical concepts• Records of its use in 1600s for teaching

midwives– Basket and leather fragments in shape of a pelvis

• Used today in a variety of industries– Airline industry has led the way

• Substantial decline in accidents from 1980s onward

• Crew resource management– Error management– Capability to detect, avoid, trap or mitigate human

error and therefore prevent fatal accidents

Simulation

Simulation allows us to expose and correct weaknesses, vulnerabilities and the potential for error before it causes harm

Simulation• Provides opportunities

– Gain skills when real world training is expensive or dangerous

– Experience– Refine and refresh skills

• Currently used in multiple disciplines– Anesthesia– General and trauma surgery– Emergency medicine– Obstetrics and pediatrics– And the list grows…….

Simulation Training• Opportunity to

practice:– Technical skills

• Hands on procedures – deliver the baby, give medication

– Cognitive skills • Critical thinking• Decision making

– Behavioral skills • Interpersonal interactions

• It is a team sport!!

Simulation in Obstetrics• Endless possibilities

– Low-frequency, high acuity events are perfect for simulation• Eclampsia, Shoulder dystocia, Hypertensive

Crisis– But it is equally effective for common, everyday

events• Ideally multidisciplinary team performing drills

– Include anesthesia, neonatology/peds staff and providers

– Combine disciplines as with Obstetric Trauma cases

• Most important is post-scenario debriefing– Participants explain, analyze and synthesize their

actions

Possible Perinatal Scenarios

Maternal– STAT C/Section– Shoulder dystocia – Difficult maternal

airway– PP Hemorrhage– Amniotic fluid

embolism – High regional

block– Seizure– Anaphylaxis– Fire in the OR– D &C’s

Neonatal– Neonatal

resuscitation– Hypovolemia– Meconium– Premature birth– Fetal anomalies

• Neural tube defect

• Diaphragmatic hernia

• Abdominal wall defect

What Simulation Does Best• Provides a safe environment – Mistakes are tolerated – Appropriate responses learned and then

practiced• Identify system-based issues and staff

responses that can be improved in response to critical clinical events– Impact of simulation training can be

monitored by tracking clinical outcomes• Reduce malpractice premiums through

incentive programs in risk-reduction

What Simulation Does Best

• Benefit communities through education of paramedics, EMTs and critical access hospitals,

• Helps build confidence, communication techniques, and skills in our newer staff

Getting a Program Started

• Core group of committed staff and providers– Need a champion! (Physician/Provider and Nurse)– It takes time to develop and run a program

• Need administrative support – and that includes financial!– You will see a return in investment – e.g.

decreased insurance premiums

• Focus on the simple things first– Think about clinical issues that have been

challenging• “Near misses”

– Consider processes that could use improvement• Time it takes to get a CS team together and

patient to OR for stat CS

THE

HOW

Getting a Program StartedIn Situ™

Simulation

Experiential learningApplication

Test for gapsID ERROR

Just Culture™

Principles of riskAccountability

Focus on Behavior

MANAGE ERROR

TeamSTEPPS™

Define the teamUse the tools

Coach to sustainMITIGATE ERROR

High

Reliability

Riley, W, Davis, S, Miller, K, Mccullough, M. A Model for developing high-reliability teams. Journal of Nursing Management. July 2010 p 556-563.

Getting a Program Started

®Team

Strategies and Tools to Enhance Performance and Patient Safety

• Evidence based• Improves outcomes• Increases satisfaction• Decreases harm

Getting a Program Started

SKILLSSituational Awareness

Standardized Language (ex: SBAR)Closed-Loop CommunicationShared Mental Model “US”

• TOOLS• SBAR• NICHD Language• Code C-section• Stop the line

®

Getting a Program Started• Write up a short script for the scenario• Provide a Brief with the Ground Rules of Safety/Trust

– Let the group manage the situation and play it out• Allow mistakes to be made• No coaching – just give clinical information to

keep the simulation moving– e.g. patient response to a medication or

procedure– Have specific tasks in mind that should be

accomplished• Medical procedure, communication, staff

interaction• Review what was and was not done when you

debrief

Getting a Program Started

• Don’t need fancy stuff– Do the simulation where the care

occurs or improvement is needed• L&D, the OR, the ED

– Use staff to act as patients– Appropriate size doll for term and

preterm babies• Neonatal resuscitation

– Video tape for debriefing

Who is Noelle?• Variety of mannequins

– Hemi-pelvis– Noelle– Baby Hal

• Clinical scenarios programmed into the simulator– Noelle speaks– Vital signs and fetal heart rate tracing

change as the scenario unfolds– Perform cervical exams, follow labor

progress and deliver baby• Breech delivery• Shoulder dystocia

Debriefing is Where the Learning Happens

1. What went well and “why”?2. What could have gone better and “why”?3. What would I do differently next time?

• Review the Types of Comments• Communication and Teamwork• Process Improvement• “Simisms”• Clinical Care

• Review Individual Communication & Teamwork Skills

Situational Awareness “ME”Standardized Language (ex: SBAR) “YOU”

Closed-Loop CommunicationShared Mental Model “US”

debrketc@sarmc.orgrenebobr@sarmc.org

Let’s Have Some Fun!