How simulation can train, and refresh, physicians for critical OB events
Perinatal teams can practice handling emergencies without endangering patients or risking litigation. Hospitals and insurers are taking notice.
IN THIS ARTICLE
The authors report no financial relationships relevant to this article.
Many senior obstetricians—you may be among them—have vivid recall of performing their first vaginal delivery as an intern or junior resident, guided by a seasoned obstetric nurse or senior resident. “See one, do one, teach one,” an unwritten motto at large teaching hospitals, aptly characterized the learning environment for many older physicians.
Regrettably, obstetric residents and fellows today face a very different situation. Restrictions on residents’ working hours, financial pressures that make attending faculty less available for supervision, and wariness prompted by malpractice litigation—all these have made such teaching cases less available. So, how can physicians-in-training acquire the skills they will need in practice? And how can experienced clinicians breathe life back into skills that they use infrequently but are nonetheless critical?
We believe the answer can be found in the educational technique of simulation, which we describe in this article.
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Simulation provides opportunities for physicians to practice, gain experience, and refresh. The technique offers a credible way to augment the educational curriculum and, even in the absence of unequivocal proof, to improve patient safety and reduce the likelihood of adverse outcomes. 1 For that reason, some malpractice insurers are making simulation training part of their safety and risk reduction initiatives.
To begin our discussion, a brief history of simulation appears below.
Maslovitz and colleagues, in a study that used simulated events, investigated errors among residents and nurse-midwives that occurred while teams managed four critical obstetric events 1 :
- eclamptic seizure
- postpartum hemorrhage
- shoulder dystocia
- breech extraction.
The most common management errors found were:
- delays in transporting a bleeding patient to the operating room (82% of the time)
- unfamiliarity with administering prostaglandin to reverse uterine atony (82%)
- poor cardiopulmonary resuscitation technique (80%)
- inadequate documentation of shoulder dystocia (80%)
- delayed administration of blood products to reverse consumptive coagulopathy (66%)
- inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%).
A brief history of simulation, in and outside medicine
Simulation has roots in prehistoric times, when it facilitated acquisition of hunting skills and prepared people for tribal games or warfare. 1 The ancient Greeks used simulation to illustrate philosophical concepts and help students understand them. 2 Today, simulation techniques are used in various industries and disciplines, especially when real-world training is too dangerous or expensive, or impossible. 3
Safety in the air. The airline industry is known for incorporating simulation techniques into training programs for pilots and flight crews. The first airplane simulator was built in 1910, after the first fatal airplane crash in 1908. 4 The need to train pilots during World War I and World War II greatly increased the use of flight simulators.
Beginning in the early 1980s, the airline industry began to use a range of risk-reduction activities designed to make commercial flying safer. Airlines established standard operating protocols and checklists, required pilots to participate in simulation-based training, and scheduled periodic skills and behavioral assessments. These changes in procedures, along with technological advances, led to a substantial decline in aircraft flight errors over the two decades that followed.
In labor and delivery. Obstetric simulators designed to illustrate the process of childbirth and teach midwives how to manage complications have been dated to the 1600s. 1 Early childbirth simulators were typically made of basket and leather fragments in the shape of a female pelvis, accompanied by a dead fetus or doll. Later, such devices were made of wood, glass, fabric, or plastic. Their use and evolution continued through the 19th and 20th centuries. 5
Computerized simulator technology was introduced during the 1960s, and widespread adoption across medical specialties began in the 1980s. 6,7 Gaba and DeAnda were among the first to adapt simulation training for healthcare providers during the late 1980s. 7
Since then, simulation training has become increasingly common in the fields of anesthesia, general surgery, and emergency medicine. Residents use simulation to train for difficult airway intubation, central venous access, adult and pediatric trauma resuscitation, and such complex surgical procedures as laparoscopic cholecystectomy. Reports of human patient simulation to reenact some or all aspects of routine and critical obstetrical events began to appear in the specialty’s journals in the late 1990s. 8,9
1. Wilson A. The Bomb and the Computer: Wargaming from Ancient Chinese Mapboard to Atomic Computer. New York: Delacorte Press; 1968.
2. Buck GH. Development of simulators in medical education. Gesnerus. 1991;48 Pt 1:7-28.
3. McGuire CH. Simulation: its essential nature and characteristics. In: Tekian A, McGuire CH, McGaghie WC, et al, eds. Innovative Simulations for Assessing Professional Competence: From Paper and Pencil to Virtual Reality. Chicago: University of Illinois at Chicago, Department of Medical Education; 1999.
4. Haward DM. The Sanders teacher. Flight. 1910;52(50):1006-1007.
5. Gardner R. Simulation and simulator technology in obstetrics: past, present and future. Expert Rev Obstet Gynecol. 2007;2:775-790.
6. Denson JS, Abrahamson S. A computer controlled patient simulator. JAMA. 1969;208:504-508.
7. Gaba DM, DeAnda A. A comprehensive anesthesia simulator environment: re-creating the operating room for research and training. Anesthesiology. 1988;69:387-394.
8. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol. 2003;102:388-392.
9. Knox GE, Simpson KR, Garite TJ. High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims. J Healthc Risk Manag. 1999;19(2):24-32.
Thompson’s study of eclampsia simulation drills 2 identified three major problems in handling this emergency:
- difficulty summoning senior staff
- multiple protocols for managing eclampsia, without a clear first-line anticonvulsant
- significant time lost gathering items required to manage seizures.
Based on what was observed in simulations, Thompson recommended 1) creating so-called eclampsia boxes that contain all necessary equipment and 2) establishing a liaison with the pharmacy to ensure consistency in supplies of magnesium sulfate.
The 5th Report on Confidential Enquiries into Maternal Deaths in the United Kingdom found that, in 66% of neonatal deaths following shoulder dystocia, “different management could have reasonably been expected to have altered the outcome.” 3
Using a standardized shoulder dystocia simulation, Deering and colleagues reported significantly higher scores for residents who were trained in the scenario, including in the timeliness of their intervention, performance of maneuvers, and overall performance. 4
Crofts, Draycott, and various colleagues developed a training mannequin for hospital staff that included a force-monitoring system comprised of a strain gauge mounted on both clavicles. After training, they found a reduction in 1) head-to-body delivery duration and 2) maximum applied delivery force after training, although these reductions did not reach statistical significance. 5,6
Where do you begin?
Starting a simulation program can be challenging: Significant financial hurdles may exist, and teamwork and communication issues can be major barriers to yielding improvements in practice. What’s the first step?
Assemble a multidisciplinary team. Include obstetricians, gynecologists, anesthesiologists, neonatologists, and other members of the perinatal or surgical team. All will be needed to create complex interdisciplinary drills or simulations.
Build consensus. Determine the scope, goals, and objectives of the project. Define measurable outcomes.
Outline a budget. Make a realistic assessment of the resources available to fund the curriculum you design.
Opening questions about a simulation training program
How do you get started?
What are the key components?
Know how adults learn
A simulation designed to raise the skill level of professionals—be they residents, nurses, or attending physicians—must recognize the special characteristics of adult learners. Unlike school children, adult learners are self-directed; they bring real-life experience to the table, are motivated primarily by a need to know, have individual learning styles, and deserve to be treated with respect.
A simulation curriculum should incorporate so-called crew resource management skills—a style of open cockpit communication of proven worth in improving airline safety. 8 Those crew skills should promote best practices in closed-loop communication (such as the readback/hearback system 9 ), information sharing, assertiveness, adaptability, and leadership skills—all elements of successful simulation. Means of coordinating, allocating, and monitoring team resources should be built into the curriculum ( TABLE 1 ).
Find the time
A practical rule to follow when designing a simulation goes by the acronym ARRON—As Reasonably Realistic as Objectively Needed. 10
The team leader should match the task to:
- time allotted
- baseline level of medical knowledge of the trainee (resident, nurse-midwife, experienced attending)
A major hurdle, especially in a community hospital, is to schedule sessions at a time when as many providers as possible can attend. Taking time off for training is particularly difficult for office-based providers; a workable schedule must take their needs into consideration—possibly with evening or weekend sessions.
Multiple nursing shifts may necessitate repeating a simulation several times. Consider having a so-called stand-down declared, in which all nonemergency cases are delayed (if hospital administration is amenable). Alternatively, the hospital may allot time for a simulation exercise during a slot for a weekly educational lecture or monthly department meeting.
What equipment is needed?
A community hospital can develop a simulation program that is focused on its educational and safety needs. For example, a broad range of birth simulators is available ( TABLE 2 ). The features and capabilities of each model vary with cost (we do not recommend any particular simulator). The ideal childbirth simulator has yet to be defined, but existing modalities can be adapted to meet specific needs of a target audience. A standard obstetric birthing pelvis equipped with an inflatable uterus for simulating uterine atony, for example, can be modified and made to bleed from the model’s cervical os to simulate postpartum hemorrhage. 11 Commercial models (mannequins) are not always necessary for OB simulation; task trainers (devices that allow repeated practice of individual skills) and standardized patients (persons trained to portray patient scenarios) can also be used.
Most hospitals do not have an extensive simulation center. Several state-of-the-art facilities exist in the United States, including:
- The Uniformed Services University of the Health Sciences, Bethesda, Md.
- the Center for Medical Simulation, Cambridge, Mass.
- the International Academy for Clinical Simulation and Research, Miami, Fla.
The Society for Simulation in Healthcare maintains a list (at www.ssih.org/public) of institutions that host a simulation center.
What are the commercially available childbirth simulators?
Models are listed in ascending order by price
• Vinyl Pelvic Model set
Accommodates cloth fetal model’s head
• Abdominal Palpation Model
Fetal head with palpable anterior and posterior fontanels; fetal body flexes for demonstration of all presentations; movable gel packs to simulate amniotic fluid
• Advanced Childbirth Simulator
Removable diaphragm end plate for manual positioning of fetus
• Obstetrical mannequin
Includes disposable umbilical cords and powder to make simulated blood
• Forceps/vacuum delivery OB mannequin
Used in Advanced Life Support in Obstetrics training programs; soft vinyl pelvis replicates the resistance encountered in an operative vaginal delivery
• Life/form birthing station simulator
Shows relationship between fetal head and ischial spines
• Obstetric Susie
Adaptive birth canal to demonstrate shoulder dystocia; ability to practice manipulation of breech
• Standard Childbirth Simulator
Covered belly cavity; removable vulva and fetus at 40 weeks gestation
• NOELLE S552 Birthing Torso
Automatic birthing system that rotates baby as it moves through birth canal
• NOELLE S551 Birthing Simulator
Inflatable airway with chest rise, IV arm for meds/fluids, vulval inserts for suturing practice
Limbs & Things
• PROMPT Birthing Simulator: Standard
Movable legs (semirecumbent, lithotomy position, McRoberts maneuver, all fours)
• PROMPT Birthing Simulator: Force Monitoring
Electronic strain gauge allows for measurement of force applied to baby as it is delivered
• NOELLE S555 Birthing Simulator
PEDI Blue full-term newborn included; nine prepackaged scenarios
• NOELLE S560 Birthing Simulator
Testing stations include ALS, NRP, and obstetrics; virtual instruments used to monitor the mother include heart rate, blood pressure, pulse oxygenation, and electrocardiogram
• NOELLE S565 Birthing Simulator
Computer interactive; instructor controls delivery as well as fetal monitor
• Full-body pregnancy simulator
Model made of lifelike materials for realistic practice
• NOELLE S575 Birthing Simulator
Wireless, tetherless, and fully responsive; built-in scenarios for crash C-section, postpartum hemorrhage, shoulder dystocia, placenta previa, and operative vaginal delivery
Limbs & Things
What topics should be covered by simulation?