Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes

Problem Addressed

• Relatively rare, but still affecting thousands: Birth trauma occurs in approximately 7.4 out of every 1,000 live births in the United States.² For example, shoulder dystocia (when the baby's shoulders cannot move past the mother's pelvis during delivery), which occurs in approximately 5 percent of births,³ can lead to birth trauma if not handled properly. Serious forms of maternal morbidity are reported in an average of less than 1 percent of births; for example, maternal cerebrovascular accident occurs in less than 0.1 percent of births, while eclampsia and postnatal hemorrhage occur in approximately 0.1 percent and 2 percent of deliveries, respectively.⁴ However, with approximately 4 million deliveries annually, thousands of women and their babies still end up being affected by these events.⁴ 
• Devastating consequences: Obstetric emergencies—particularly those resulting in birth trauma—are emotionally devastating to families and result in long-term costs to providers and society, including rapidly rising litigation expenses (leading some physicians to stop delivering babies altogether) and an escalation in use of costly Cesarian sections and operative vaginal deliveries to minimize the potential for birth trauma in high-risk situations.⁵
• Largely unrealized benefits of practicing team responses: The most common adverse events that occur during birth are largely preventable.¹ For example, proper maneuvering can prevent injury in shoulder dystocia cases. Yet, up to 25 percent of deliveries in these cases result in an injury to the nerves that control movement and sensation in the arm, with permanent damage occurring in up to 10 percent of babies.³ While simulation training can provide opportunities to hone the teams response during actual emergencies and prevent adverse events,⁶ very few hospitals have such programs in the United States.

Description of the Innovative Activity

• Program logistics: All personnel working in the labor and delivery suite, including obstetrician/gynecologists, pediatricians, anesthesiologists, nurses, clerical staff, and others, attend a mandatory annual 2-day training through the PRactical Obstetric Multi-Professional Training (more commonly known as "PROMPT") system. At the University of Kansas Hospital, the course is offered quarterly, with roughly 50 individuals attending each session. Sessions are led by masters-level nurses and senior labor suite nursing staff who have completed PROMPT training previously. Trainers receive special training on how to prepare for the course, present didactic materials, and run the simulations
• Preparation for Rehearsal: The sessions emphasize two key areas where care processes need to be improved—responses to common emergency scenarios and structured communication to facilitate information sharing during an actual emergency. 
  • Optimal response to emergency scenarios: Didactic sessions lead to practice change by outlining the care steps clinicians should take to optimize outcomes when faced with an obstetric emergency. Sessions focus on the appropriate response to a variety of potential emergency situations that may occur, including maternal hemorrhaging, maternal arrest, eclampsia (convulsions), hypertensive crisis (a severe increase in the mother’s blood pressure that can lead to a stroke), umbilical cord prolapse (in which the cord passes through the cervix ahead of the baby), shoulder dystocia, breach delivery, forceps delivery, multiple gestation, and interpretation of fetal heart rate tracings. Didactic modules are held during the morning of each training day, structured as a series of short (15-minute) lectures, followed by 15 minutes of audience participation allowing for questions, discussion of current practices, and suggestions for process change.
  • Structured communication techniques: Participants learn structured communication techniques as part of a didactic module and then watch a videotape of two different situations that illustrate poor and optimal communication. The session teaches an organized method for communicating vital information about the patient’s condition and instructions regarding equipment, testing, and staff. This initial communication is followed by the participant's repeating of the information to confirm receipt and understanding. Participants then use these communication techniques in the simulations (see below), and are encouraged to use them in daily care situations. Participants also receive and learn to use forms to document communication. 
• Rehearsals through simulated drills and real-time performance feedback to influence actual care:  After the morning modules, participants take part in a half day of simulations that allow them to enact the situations and practice the care steps discussed earlier in the day. Five teams with 10 participants each rotate through five stations, each representing a different emergency scenario. Teams practice the care steps related to the scenario, with the intent that these care steps will then be used during actual emergencies. In most cases, midwives, nurses, and medical students act as “patients”; sometimes, participants use a plastic pelvis and a baby doll for general teaching/demonstration purposes. (Occasionally teams use high-fidelity simulation mannequins, but these are not necessary for the program.) During the simulation, the trainer reviews the team’s performance and offers realtime feedback regarding clinical and communication processes. For example, the trainer may stop the team to remind them of an omitted step or may change the simulation to reflect the negative consequence of forgetting that step.

References/Related Articles

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Results

• Anecdotal reports of better management of emergency situations: Coincidentally, the hospital's labor and delivery unit faced three emergencies during the first week after the initial training: a postpartum hemorrhage, a baby with shoulder dystocia, and a breech delivery. Staff resolved all three emergencies successfully by using techniques practiced during simulations, achieving positive outcomes. All involved staff commented on how well prepared they felt to handle these cases as a result of the simulations. Although quantitative data to date is insufficient to draw conclusions about the program's impact on outcomes, anecdotal reports over the past 2 years suggest that clinician performance during emergency situations has improved since implementation of PROMPT.
• Savings on annual liability premiums: Since adopting PROMPT, the hospital’s annual malpractice insurance premium has fallen significantly (actual cost savings not available).

• Better outcomes: A retrospective cohort observational study found that, after the introduction of PROMPT, the number of infants with Apgar scores less than or equal to 6 decreased from 86.6 to 44.6 per 10,000 births, and the number of infants with hypoxic-ischemic encephalopathy (central nervous system damage resulting from inadequate oxygen) decreased from 27.3 to 13.6 per 10,000 births.⁶ Another retrospective observational study found that the program led to a 70-percent reduction in brachial plexus injuries following shoulder dystocia.⁷ 
• Improved task completion, medication administration, and response times for eclampsia patients: An RCT focused on the care of patients with eclampsia found that PROMPT training increased the completion rates for basic tasks (100-percent completion rates in the training group, compared to 87 percent in the control group); led to quicker completion of these tasks (27 seconds versus 55 seconds); increased administration of appropriate medications (92 percent versus 61 percent); and reduced median administration time for these medications (by 116 seconds).⁸
• Enhanced knowledge: A prospective RCT found that obstetrician and midwife knowledge about emergency management significantly increased after training, with scores on a 185-question multiple choice questionnaire increasing by an average of 20.6 points.⁹ 

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtaining approval from senior leadership: Dr. Weiner proposed the adoption of the evidence-based program,^6,7,8,9 PROMPT to senior hospital administrators, who reacted enthusiastically to the idea.
• Obtaining and “Americanizing” PROMPT materials: The program, PROMPT is an evidence-based program developed and tested in in the UK.  Dr. Weiner received approval to license and distribute PROMPT materials in the United States. He amended the materials for American audiences by adjusting language and ensuring that the clinician relationships and organizational processes described reflected the U.S. health care system.
• Selecting and training the trainers: Dr. Weiner identified staff to serve as trainers, selecting obvious choices for the role, including, for example, the director of nursing education and a perinatologist. He then administered the course to these individuals and held several rehearsals.
• Piloting and rolling out the program: Dr. Weiner held a “trial run” of the program during an abbreviated, half-day session that included obstetricians, faculty, and nurses. After this trial, the labor and delivery department scheduled all involved individuals (approximately 200 people) for one of two 2-day courses, conducted several days apart.
• Adjusting schedule: Because training all individuals during the same week proved logistically difficult, the hospital now schedules sessions on a quarterly basis, with approximately 50 people attending each session.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: The primary costs relate to the labor expenses needed to provide patient coverage while staff members attend the program. Mannequin simulators for shoulder dystocia can also be purchased from manufacturers, but the course can be run without these mannequins or any other specialized simulation equipment. In addition, because the University of Kansas Hospital must pay PROMPT a royalty fee each time a U.S. hospital adopts the program, the hospital requires these adopters to pay a one-time fee equal to $1 per annual delivery to cover this expense. 

Funding Sources

University of Kansas Hospital

Tools and Other Resources

Getting Started with This Innovation

• Obtain commitment from all parties: Senior management, clinicians, and front-line staff must all believe in the value of process improvement if the program is to be successful. Although academic medical centers can require their faculty to participate, community hospitals may find it more difficult to mandate that physicians do so.
• Customize to site-specific characteristics: Adopters should customize the program to reflect the care and operational processes of their own institutions.

Sustaining This Innovation

• Repeat annually: Sessions should be repeated annually to refresh clinician skills in handing these relatively rare events. PROMPT studies have shown that the skills and learning persist for approximately 1 year but then begin to wane if not refreshed.¹⁰ 
• Seek insurer support: Share data with insurers on program outcomes and request that they lower malpractice premiums for hospitals and providers that participate in the program; lower premiums create a strong incentive for participation.

Additional Considerations and Lessons

The PROMPT program has won numerous awards in the United Kingdom, including (but not limited to):

• Obstetrics & Gynaecology Team of Year 2007 (Royal College of Obstetricians and Gynaecologists, United Kingdom)
• Hospital Doctor of the Year 2007 (Royal College of Obstetricians and Gynaecologists, United Kingdom)
• Clinical Category Winner and Overall Winner, National Institute for Clinical Excellence (NICE) Shared Learning Awards, December 2008

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