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Outcome-based research in Obstetric simulation. Dr Jo Crofts Academic Clinical Lecturer in Obstetrics University of Bristol, UK. Outline. Why simulation training is required 9 years of progress Simulation and clinical outcomes Characteristics of effective training

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outcome based research in obstetric simulation

Outcome-based research in Obstetric simulation

Dr Jo Crofts

Academic Clinical Lecturer in Obstetrics

University of Bristol, UK

outline
Outline
  • Why simulation training is required
  • 9 years of progress
  • Simulation and clinical outcomes
  • Characteristics of effective training
  • Outcome based research is required
  • Future of obstetric simulation
childbirth is dangerous
Childbirth is dangerous

1000 women die every day due to pregnancy and childbirth complications that ‘could have been prevented’

the safety problem
The Safety Problem
  • 1 : 12 labours associated with adverse outcomes

Nielsen P at al, Obstet Gynecol 2007

  • 50% adverse outcomes preventable with better care

CESDI – 4th Annual Report. 1997

CEMD – Why Mothers Die. 1998

CEMACH – Saving Mothers Lives 2007

very expensive
Very expensive
  • NHS Litigation Authority £633 million in settled negligence claims 2007-08
  • £221 million for Obstetric Claims
  • £1 billion for additional bed days to deal with preventable harm
  • Human costs ?

House of Commons Health Committee: Patient Safety Report. 2009

training
Training

Simulated emergencies should be organised to improve management of rare obstetric emergencies

CESDI – 4th Annual Report 1997

CEMD – Why Mothers Die 1998

NHSLA. CNST Maternity Standards 2000

CEMACH – Saving Mothers Lives 2007

Kings Fund: Safer Births everybody’s business. 2008

Include teamwork training

To Err is Human: building a safer health system. 2000

9 years of progress
9 years of progress

2003

  • No objective evaluation
  • Difficult to demonstrate any benefit
  • Decade after first recommendation - neither a national curriculum, nor a system for provision

Black R & Brocklehurst P. BJOG 2003

outcome based research
Outcome based research

Kirkpatrick, D. (1998). Evaluating Training Programs: The four levels. San Francisco, Berrett-Kochler Publishers.

slide9

MCQ

Clinical Scenarios

MCQ

Clinical Scenarios

Simulation Centre

No team training

One day

Local Hospital

No team training

One day

Local Hospital

Team training

Two days

Simulation Centre

Team training

Two days

SaFE Study

Pre-training Assessment

Training Intervention

Post-training Assessments

3 weeks, 6 months and 12 months

knowledge summary
Knowledge Summary
  • Significant increase in knowledge following training
  • 93% increased MCQ score
  • Knowledge at 6 & 12 months was significantly higher than pre-training
  • None of the training interventions appeared to be superior

Crofts, J., D. Ellis, et al. (2007). "Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training." BJOG: An International Journal of Obstetrics and Gynaecology 114(12): 1534-1541.

eclampsia
Eclampsia
  • 140 staff randomised to training on patient-actor or whole body simulator
  • Following training
    • completion of basic tasks (87% to 100%)
    • administration of MgSO4 (61% to 92%)
    • medication given 2 minutes earlier
  • No differences in training style except improved communication with actress

Ellis et al. (2008). "Hospital, Simulation Center, and Teamwork Training for Eclampsia Management: A Randomized Controlled Trial." ObstetGynecol 111(3): 723-731.

shoulder dystocia simulation
Shoulder dystocia simulation
  • 140 staff randomised
  • Training is required
    • Pre-training 43% successful shoulder dystocia
  • Simulation improves performance
    • Post-training 83% successful shoulder dystocia
  • PROMPT mannequin
    • Improved delivery rate (72% vs 94%)
    • Shorter delivery time (161s vs 135s)

Crofts, Bartlett, et al. (2006). ObstetGynecol 108(6): 1477-85..

Crofts, Fox, et al. (2008). ObstetGynecol 112(4): 906-12.

not all training equal
Not all training equal
  • Two UK cities
  • Similar demographic
  • Shoulder dystocia training started in 2000
    • City 1: 70% decrease in OBPI
    • City 2: 100% increase in OBPI

Draycott et al. Obstet Gynecol 2008; 112: 14-20

MacKenzie et al. Obstet Gynecol 2007; 110: 1059-1068

differences in training
Differences in training

Effective

  • 98% staff
  • Multi-professional
  • PROMPT model
  • Simple algorithm

Ineffective

  • ~60% staff
  • Separate
  • Low fidelity model
  • Mnemonic
labour delivery crm trial
Labour & Delivery CRM trial
  • 15 hospitals (6 military, 9 civilian)
  • 28,536 deliveries
  • 4 month intervention
    • 4 hour didactic training (CRM)
    • Team structure implementation
  • Primary outcome: reduction in overall frequency of adverse outcomes

Nielsen PE, Goldman MB, Mann S, Shapiro DE, Marcus RG, Pratt SD, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol. 2007 Jan;109(1):48-55.

labour delivery crm trial1
Labour & Delivery CRM trial
  • No difference in adverse outcomes (both groups improved)
  • Problems
    • CRM does not work / as implemented ?
    • Short implementation period
    • Wrong measures ?
    • Hawthorne effect ?
    • Underpowered ?
nine years of progress
Nine years of progress
  • What works
  • Where
  • Why
  • What next……?
common effective themes
Common Effective Themes
  • Simulation of emergencies
  • High fidelity training tools
  • Situated ‘Local’ training
  • Nearly 100% staff
  • Multi-professional
  • Insurance based financial incentives

Siassakos, Crofts, et al. (2009). "The active components of effective training in obstetric emergencies." Bjog 116(8): 1028-32.

does simulation work
Does Simulation work ?

Yes

Increasing retrospective data suggesting improvements in neonatal outcome after the introduction of simulation training

(Some, but not all)

can we do better
Can we do better ?

Yes

Increasing retrospective data suggesting improvements in neonatal outcome after the introduction of simulation training

nine year vision
Nine year vision
  • Effective evidenced based training to reduce preventable harm
    • All staff
    • All mothers & babies
  • Improved training materials
  • Commit to more, and better research for the future
    • Prospective
    • Hard clinical outcomes
the future
The Future
  • Whole body mannequins
    • Sepsis
    • Maternal collapse
  • Virtual reality
    • Instrumental delivery
the future1
The Future
  • Accessible training
  • Simple training aids
simulation training is required
Simulation training is required
  • 1000 women die every day due to pregnancy and childbirth complications that ‘could have been prevented’
  • Almost all of them (99%) live and die in developing countries

World Health Organisation

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