Multidisciplinary in situ simulation to improve emergency obstetric care

Introduction

Trauma among pregnant women occurs during 1 in 12 pregnancies¹ and pregnant trauma patients are twice as likely to die or suffer significant morbidity compared with their non-pregnant counterparts.² Management of traumatic injuries in the obstetric patient requires a multidisciplinary approach for rapid assessment, treatment and transport to optimise maternal and fetal outcomes. Multidisciplinary team training using simulation for obstetric emergencies can improve clinical skills, teamwork and patient safety.³ Simulation training can also enhance communication among providers that can further increase the efficiency of the emergency response.⁴ According to the American College of Obstetricians and Gynecologists Committee on patient safety and quality improvement, simulation training can identify and correct common clinical errors made during emergencies, as well as allow team members to practice effective communication in a crisis.⁵

Medical simulation is widely utilised in the obstetric and surgical residency curricula at our institution. Additionally, our nursing onboarding involves a significant amount of simulation, as does the ongoing education of the other allied health professions. However, we recognised that our training was occurring in educational silos and sought to improve teamwork, role clarity and the use of protocols among multidisciplinary team members who respond to traumatically injured pregnant patients. We conducted an in situ simulation and debriefing to train our multidisciplinary team on the unique emergency care needs of pregnant trauma patients and to identify latent safety threats (LSTs). We also used the simulation to clarify and evaluate existing protocols. We hypothesised that this simulation-based training would improve the confidence and decrease the level of difficulty for all learners.

Methods

All personnel who respond to obstetric emergencies in the emergency department (ED) trauma bay completed the in situ simulation as a multidisciplinary team. Participants included resident and attending physicians as well as nurses from the ED, trauma, labour and delivery (L&D) and neonatal intensive care unit (NICU). Additionally, allied health professionals from emergency medical services, respiratory therapy, pharmacy, operating room and anaesthesia staff participated in the training. To accommodate the training needs of all the specialty teams involved, the simulation was performed twice, each with a different group of learners. Additionally, to accommodate those who could not participate, the simulation was live streamed to a conference room where other learners could observe.

The in situ simulation started with a term pregnant patient brought into the ED trauma bay by emergency medical service (EMS) personnel. The patient was involved in a high-speed motor vehicle collision with prolonged extrication. The patient was intubated and had two large bore intravenous placed by EMS. Despite this, the patient was hypotensive and tachycardic. The patient had diminished breath sounds with bag-valve-mask ventilation. The simulation progressed with deterioration of the patient’s clinical status, resulting in cardiopulmonary arrest. The teams performed decompressive thoracostomies of the mother’s chest, and perimortem caesarean section and delivery of the neonate.

A structured debriefing of all participants and observers occurred following the simulation. Physician and nursing content experts from trauma, obstetrics (OB), ED and NICU were present to provide context and clarification when necessary.

We used preanonymous and postanonymous surveys to evaluate our in situ simulation training. The survey consisted of six items for the participants to rate their confidence level and the same six items for their perceived level of difficulty in performing obstetric emergency care. A 5-point modified Likert scale was used with 5 for ‘extremely confident’ or ‘extremely difficult’ to 1 for ‘not confident’ or ‘not difficult’. The percentage of participants who selected 3, 4 or 5 on the scale in each item of the presurvey was compared with that of the postsurvey.

Results

There were 66 participants for the simulation. Twenty-two learners actively participated in the simulation while 44 learners observed. The appropriate team members responded to the trauma activation. The surveys were distributed and collected in person immediately before and after the simulation. Forty-seven participants (71%) completed the presurvey and postsurvey.

Analysis of the presurvey and postsurvey results showed the in situ simulation significantly increased the overall confidence in managing obstetrical emergencies by all involved groups (table 1). The survey items related to ‘provider roles’ had the biggest improvement. The percentage of participants expressing confidence in their role and identifying the role of other team members during an OB trauma increased by 30% (p=0.0016) and 41% (p<0.0001), respectively. In the presurvey and postsurvey, the majority of participants did not perceive performing individual task as difficult or somewhat difficult. The perceived level of difficulty in all survey items did not significantly change after the simulation (table 1).

Table 1.

Changes in responses regarding confidence level and perceived level of difficulty in the presurvey and postsurvey

Survey items	Pre	Post	Post–pre	P value
	% (n), Participants who reported 3, 4 or 5*	% (n), Participants who reported 3, 4 or 5*	% Difference
I. Rate how confident you are in your ability to perform the following:
​Contact appropriate personnel necessary during an OB trauma	​60 (28)	83 (38)	23	0.0147
​Communicate with the appropriate personnel during an OB trauma	​55 (26)	77 (36)	22	0.0251
​​Obtain equipment during an OB trauma	​36 (17)	60 (28)	24	0.0205
​My role during an OB trauma	​55 (26)	85 (40)	30	0.0016
​Identify other team members roles during an OB trauma	​46 (21)	87 (41)	41	<0.0001
​Apply the appropriate protocols during an OB trauma	​46 (21)	70 (33)	24	0.0197
II. Rate your perceived level of difficulty for the following:
​Contact appropriate personnel necessary during an OB trauma	7 (3)	6 (3)	−1	1.0
​Communicate with the appropriate personnel during an OB trauma	16 (7)	11 (5)	−5	0.4846
​​Obtain equipment during an OB trauma	22 (10)	23 (11)	1	0.9091
​My role during an OB trauma	11 (5)	9 (4)	−2	0.7516
​Identify other team members roles during an OB trauma	16 (7)	21 (10)	5	0.5397
​Apply the appropriate protocols during an OB trauma	27 (12)	13 (6)	−14	0.0964

*1=not confident or not difficult; 2=somewhat confident or somewhat difficult; 3=confident or difficult; 4=very confident or very difficult; 5=extremely confident or extremely difficult.

Discussion

This project has demonstrated that our in situ simulation was effective in training our multidisciplinary teams on traumatically injured obstetric patients. The simulation allowed participants to practice managing obstetric emergency care as a team. The overall confidence in performing obstetric emergency care increased significantly after the simulation. Team members expressed improved confidence in applying appropriate protocols, obtaining equipment, understanding their role and identifying the roles of other team members. The simulation may have ‘raised the bar’ in the perceived level of difficulty as participants developed greater knowledge. Thus, the poststimulation responses in the perceived level of difficulty ended up being lower than prestimulation, even though positive change may have occurred.

As the result of this simulation, our multidisciplinary team was able to identify LSTs during a debriefing session. The LSTs identified were related to the fetal emergency care process, NICU equipment and communication. These issues and feedback were taken back to the respective departments. Specific care location, workflow and available resources were discussed for areas of improvement.

In the future, we plan to offer more simulations similar to this one to new members of the multidisciplinary team, including new OB residents, surgery residents, ED attendings, L&D nurses and NICU staff. However, the frequency of this training remains to be determined. With obstetric trauma an all too common reality, it is important for those involved in caring for these patients to feel confident and empowered to act quickly in order to achieve the best possible outcomes, particularly when more than one life is at stake.