2015 Birth Outcomes Initiative Symposium · 2015 Birth Outcomes Initiative Symposium November 10, 2015 Breakout Session 1 & 3 Dr. Scott Sullivan Michelle Flanagan, RNC, BSN Shane

2015 Birth Outcomes Initiative Symposium November 10, 2015

Breakout Session 1 & 3

Dr. Scott SullivanMichelle Flanagan, RNC, BSNShane Gravel, BA NREMT-P

Objectives

• Discuss the use of simulation in the perinatal setting to improve patient outcomes

• Verbalized steps to set up simulation scenarios at their own facility

http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.htmlhttp://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.htmlhttp://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2015/safe-motherhood-aag-2015.pdf

Severe Maternal Morbidity Indicator1. Acute myocardial infarction2. Acute renal failure3. Adult respiratory distress syndrome4. Amniotic fluid embolism5. Aneurysm6. Cardiac arrest/ventricular fibrillation7. Disseminated intravascular coagulation8. Eclampsia9. Heart failure during procedure or surgery10. Internal injuries of thorax, abdomen, and pelvis11. Intracranial injuries12. Puerperal cerebrovascular disorders13. Pulmonary edema14. Severe anesthesia complications15. Sepsis16. Shock17. Sickle cell anemia with crisis18. Thrombotic embolism19. Blood transfusion20. Cardio monitoring21. Conversion of cardiac rhythm22. Hysterectomy23. Operations on heart and pericardium24. Temporary tracheostomy25. Ventilation

Can it happen to you?

Are you prepared?

Audience Poll

• Do you deliver babies? / Take care of neonates?• Do you work in:

– Level 1 Hospital– Level 2 Hospital– Level 3 Hospital– Teaching Hospital

• Have you ever had a bad or unfavorable outcome?• Do you have access to a Simulation Lab on a regular

basis?• Do you think Simulation is too difficult or too expensive

for your facility?

Simulation in the perinatal setting to improve patient outcomes

Practice Makes Perfect

Scott Sullivan, MD

• Director, Maternal Fetal Medicine

• MUSC

• Conflicts

– Research funding

• Lumara

Biases

• Persecution as intern

• Baseball

• Band

• Airlines

Objectives

• Rationale for simulation

• Applications

• Disadvantages of simulation

• Suggestions

– Individual and team

Rationale for simulation

Rationale for simulation

• Equivalent of a 747 going down every day

Air Lines

• Safest mode of travel

• Obsession with failure

• Checklists

• Simulation

Rationale for simulation

• Complex systems

• Dangerous outcomes

• Large, rotating crews

• Incomplete prediction

Military

• Simulate everything

• Prepare for many outcomes

• Historical failures

• Checklists

NEJM 2013

Training of the Individual

Individual Skills

Individuals

• 10% don’t get mentoring on handedness

• Few get offered Left-handed instruments

• 55% annoyed faculty

• 28% forced to switch handedness

Deliberate Practice

• Individual motivation

– Exertion of effort to improve

• Pre-existing knowledge taken into account

• Immediate informative feedback

• Repeatedly perform or repeat similar tasks

• Controlled setting

Ericsson KA et al. Psych Review. 1993

Ericsson: 10,000 hour rule

Ericsson KA et al. Psych Review. 1993

Component training

Component Training

Individual Skills

Component training

Loss of skills

• Dimunition of skills or knowledge

• Following periods of nonuse

• Influenced by

– Task characteristics

– Methods of original learning

– Individual differences

Arthur W et al. Hum Perform 1998

Types of Simulation

• Low fidelity

• Screen based- video game-type

– Colonscopy

– Xbox/PS/Wii: “wax on wax off”

• Partial task trainer devices

– Amniocentesis/PUBS trainer

– Vesico-amniotic shunt

Call of duty- really!?

Adams et al. Journal of surgical education 2012

Bringing it all together

Team

Training

Component Training

Individual Skills

What can we learn from others

• Baseball

– Preparation

– Individual/Unit/Team

– Debriefing

Simulation Center

Team dynamics in practice

• Obstetrics emergencies

– Unpredictable, sudden

– Can occur in healthy, low risk women at term

• Rapid coordinated response

• Ad hoc teams

– Varying experience

Burke C et al. JPNN 2013

What else can we learn

• Band

– Individual/Section/Band

– Improvisation

– Sight Reading

Technical

fundamentals

Psychomotor

skills/Memory

Ability to read,

recognize,

remember

Awareness of

music’s structure

and theory

Advantage of In Situ

• Greater ease of access

• Reduced time/expense of travel

• Greater familiarity with equipment/surroundings

• Address local issues

• May more closely approximate clinical scenario

In Situ Simulation

• Full-team drills

• Full environment simulation (FES)

• Kaiser Permanente experience

– Exclusively uses In Situ Simulation

– Overestimation of ability to multi-task

• Urgent cases

– One OR favored over others

Preston P. Seminars in Perinatol. 2011

Sim Center vs. In Situ

• SaFE study

• 140 participants

• Sim center vs. in situ

• No difference

– Knowledge

– Improved performance

Ellis D, et al. Obstet Gynecol 2008

Applications for FES in OB

• Postpartum hemorrhage

• Shoulder dystocia

• Ecclampsia

• Trauma/Cardiopulmonary resuscitation

• Operative vaginal delivery

Debriefing: 3D’s

• Defuse

– Elicit reactions/emotions

– Describe events

• Discover

– Analyze and evaluate

– Mental models

• Deepening

– Connecting learning to practice

Disadvantages of Simulation

• Cost

– Need to remove participants from clinical care

– Equipment/Instructors/Models

– Personnel

• Lack of realism

• Overemphasis on crisis management

• Rigidity/Stereotyped response

• Disruptive

What should we do?

• Reconsider how we educate–What should be lecture what could be

simulation– Simulation is not a sub for good teaching– Focus on developing critical thinkers

• Recognize medicine as a team sport– Lead–Participate

Summary

• Health care is a team effort

• We should pursue excellence

• Simulation important educational tool

– Effective practice

– Team practice

– Feedback

“To practice a discipline is to be a lifelong learner. You never arrive.”

"In the long history of humankind (and animal kind,

too) those who learned to collaborate and improvise

most effectively have prevailed."

Charles Darwin

Steps to Set up Simulation Scenarios

What is Simulation? • “Simulation is a technique for practice and

learning that can be applied to many different disciplines and types of trainees. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often “immersive” in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion.”

Fatimah Lateef. Simulation-based learning: Just like the real thing. J Emerg Trauma Shock. 2010 Oct-Dec; 3(4): 348–352. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966567/

Simulation Breakdown

Features of simulation which best facilitate learning:

• The ability to provide feedback

• Repetitive practice

• Curriculum integration

• The ability to range the difficulty levels

Educational benefits of simulation in medical education

• Deliberate practice with feedback

• Exposure to uncommon events

• Reproducibility

• Opportunity for assessment of learners

• The absence of risks to patients

Fatimah Lateef. Simulation-based learning: Just like the real thing. J Emerg Trauma Shock. 2010 Oct-Dec; 3(4): 348–352. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966567/

Features of high fidelity simulation that lead to effective learning• Integrate simulators into the overall curriculum

• Clearly define outcomes and benchmarks for the learners to achieve using simulators

• Learners should repetitively practice skills on the simulator

• Learners should practice with increasing levels of difficulty if available.

• Provide feedback during the learning experience with the simulator.

• Adapt the simulator to complement multiple learning strategies.

• Ensure the simulator provides for clinical variation if available.

• Learning should occur in a controlled environment

• Provide individualized (in addition to team) learning on the simulator

• Ensure the simulator is a valid learning tool

Abdulmohsen H. Al-Elq. Simulation-based medical teaching and learning. J Family Community Med. 2010 Jan-Apr; 17(1): 35–40. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195067/?report=printable

Advantages of simulation• Practicing hands-on and invasive procedures• Continuing and repeated practice• The ability to allow errors to continue to their natural

conclusion• Risks to patient and learners are avoided• Undesirable interference is reduced• The opportunity for same scenario to be accessed by

multiple students providing similar learning opportunities• Planning clinical cases based on student need, rather than

patients’ availability.• Exposure to rare and complex clinical situations• Immediate feedback during debriefing sessions• The use of real medical equipment• Transfer of training from classroom to real situation is

enhanced• Retention and accuracy are increased• Standards against which to evaluate student’s performance

and diagnose educational needs are enhanced.

Abdulmohsen H. Al-Elq. Simulation-based medical teaching and learning. J Family Community Med. 2010 Jan-Apr; 17(1): 35–40. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195067/?report=printable

What Impacts Simulation Training?

• “For simulation-based learning, learning outcomes depend not only on knowledge, practical skills and motivational variables, but also on the onset of negative emotions, perception of own ability and personality profile.

• … Rather, it seems necessary to establish a simulation setting suitable for the education level, needs and personality characteristics of the students.”

Schaumberg, Alin. The matter of ‘fidelity’: Keep it simple or complex?. Best Practice & Research Clinical Anaesthesiology29 (2015) 21-25.

Where do you start?

Image from: http://www.photo4design.com/stock-photo-pile-of-colorful-lego-blocks-76885#.Vjy_x2eFO_4

Setting up for your Scenarios1. Target Audience?

Nurses Physicians Obstetric Antepartum Labor Newborn Nursery Neonatal/Special Care Nursery Seasoned Staff New Staff

2. What are your education goals for the Simulation education? Teaching new techniques Reviewing emergency situations

3. What is your time frame? Will you have multiple sessions? How many people can you have

in each session Will there be a didactic

component?Hint:

Team training works best with simulation. A mix of staff creating a

similar staffing selection to your unit makes for best learning group.

Hint: The larger the group, the less opportunity for participation.

Image from: https://www.google.com/search?q=image+%2B+Legos+sorted+by+color&rls=com.microsoft:en-US:IE-Address&tbm=isch&tbo=u&source=univ&sa=X&ved=0CB0QsARqFQoTCPf1j72J_MgCFUE4PgodvJQPwA&biw=1920&bih=916#imgrc=XmF5QSwapGuuUM%3A

Setting up for your Scenarios4. What equipment/budget do you have?

I have low fidelity equipment I have access to high fidelity equipment I have no equipment and no budget!

5. Where will you hold the learning sessions? In Situ

Labor and Delivery Unit Postpartum Unit Nursery

Simulation Center Classroom

6. Plan Learning Objectives– Consider, “What do I want the take away message to be for the

participants”?– What should happen in scenario? (Scenarios should reflect case details

similar to do those that have or may occur in your facility) – Will you provide Nursing CE or Physician CME Credits?

Setting up for your Scenarios

7. Decide on Scenario Normal Birth Shoulder Dystocia Eclamptic Seizure Abruption Cord Prolapse Breech Delivery Neonatal Resuscitation Postpartum Hemorrhage Other Procedures

8. Set your Date9. Prepare your Staff

– Will this be a “surprise” or scheduled event?

Setting up for your Scenarios

10. Gather your staff that will be working the scenario?• Need someone to “run” the scenario• Who will debrief the group?• Who will “reset” the room (if multiple groups)

11. Gather Equipment• Supplies depend on the scenario you will need• What do you need?

Abdomen/Belly Simulated blood Pads/Chux Bed/Table Fetal Monitoring Strip IV Tubing Non-Rebreather Face Mask Gloves Baby for resuscitation Neonatal resuscitation equipment Person(s) for role play of the pregnant woman Other???

Hint: Expired supplies make for

great education equipment

Image from: http://www.healthedco.com/index.php/advanced-childbirth-simulator-beige.html

http://www.acog.org/-/media/Districts/District-II/PDFs/SMI/v2/he-11-AF-140515-OB-Simulation-Drills-Info.pdf?dmc=1&ts=20151106T1103290498

Making it Realistic

• How to set up realistic simulations in different environments

• Hints/Tips

Debrief

• “The importance of debriefing after a simulation-based team training exercise cannot be overemphasized. Debriefing is the formal reflective period that allows the participants to integrate the experience of simulation with earlier knowledge.”

• Key components:– Trust and confidentiality– Focus on learning objectives– “normalize” their feeling about the

simulation– Discuss what went well and what

could be improved

Clark, et al. 2010. “Team Training/Simulation” Clinical Obstetrics and Gynecology. March 2010, Volume 53, Number 1.

Follow up

• “Our feedback on the learning activity was positive, bur for it to be considered truly successful, outcome data should also include staff nurses’ feedback following a real-life emergency and how the simulation experience influenced team performance during an actual event.”

• Chichester, M. “A Cost-Effective Approach to Simulation-Based Team Training in Obstetrics” Nursing for Women’s Health December 2014/January 2015. Vol 18 Issue 6.

What is happening in SC?

• SC DHHS Grant

• 5 Pilot Sites

• 2 year grant to provide on-site Simulation training to all delivering hospitals in South Carolina

• Palmetto Health / USC School of Medicine Simulation Center

– Mobile Simulation unit - “SimCOACH”

Supporting Vaginal Births

BOI SC Experience

Numbers EducatedSupporting Vaginal Birth Initiative - SC BOI

Number of Hospitals Number of Healthcare Providers Educated

(MD, CNM, RN, RT, Medical Student, Residents)

5 Pilot Sites (September 2014 – January 2015)

148

Current Training – 16 hospitals

(April 2015 – October 2015)

394

Total 542

*24 hospitals scheduled for training between 11/2015 - 04/2016

The Simulation

OB Emergency Situations / Neonatal Resuscitation

Goals:

• Life-like scenario

• Provide opportunity to review and practice

• Learn and have fun!

Nursing CE’s and Physician CME’s

Audience Participation Time!

• We need some volunteers!

For those of you in the audience:

• Watch the scenario

• What was the affect of the volunteers initially? Did that change through the scenario (i.e. were they engaged?)

• How did the simulation leaders gain the trust of the participants?

• What was the outcome?

• What kind of learning happened?

Last minute notes…• To improve effectiveness of training:

1. The physicians must be “on board”2. Concept of teamwork become part of the “DNA” of the healthcare

profession3. CRM (Crew Resource Management) is supplemented by other

teamwork-focused training strategies4. The design, development, and delivery of CRM are scientifically

rooted5. CRM training is designed systematically6. CRM is part of a learning organizations strategy to promote patient

safety/quality care7. Teamwork is rewarded and reinforced by the healthcare provider8. CRM training is evaluated at multiple levels of specific outcomes9. CRM is supported by simulation or practice-based approaches10. The healthcare provider is “ready” to receive training11. The patient is part of the team12. The team training is recurrent

Adapted from: Clark, et al. 2010. “Team Training/Simulation” Clinical Obstetrics and Gynecology. March 2010, Volume 53, Number 1.

Questions?• Thank you!

• Please visit the SimCOACH!