Noelle Edwards is admitted to the hospital in active labor, with an expected routine delivery. Two hours later, the fetal monitor shows a decelerating heart rate, and her nurse must set into motion the complex series of actions required for an emergency cesarean section. To meet the 30-minute “decision-to-incision” standard, her OB team needs the coordination seen in NBA playoffs. But whereas basketball players routinely rehearse their split-second maneuvers, obstetrical practitioners rarely face emergencies, and have had little opportunity to practice them—until the advent of simulation training.
Education Out of the Classroom
Simulation drills use high-tech equipment to bring a maternal–fetal crisis to life. Noelle Edwards is, in fact, a state-of-the-art mannequin, recently used in code-pink drills at Swedish Edmonds Hospital. Participants in this adrenaline-filled event included obstetricians, anesthesiologists, family practice physicians, labor and delivery nurses, scrub technologists, and unit secretaries.
Simulation training is relatively new to obstetrics, practiced at only a handful of hospitals in the nation.1 Physicians Insurance offers this opportunity at no charge through our unique partnership with the Gossman Simulation Center at Swedish First Hill. Together, we’ve conducted successful shoulder dystocia drills at Evergreen Medical Center and Harrison Medical Center. The drills at Swedish Edmonds were our first in emergency cesarean section. “Why is it hurting so much?” Noelle wants to know. “Your baby might be happier in a different position,” her nurse replies, calling for assistance. “Let’s move you on your side to see if that helps.” So begins the escalating drama, as a second nurse arrives to aid with repositioning. Shortly after, Noelle’s family physician responds to the page, and receives a synopsis of events. The fetal heart rate remains low. With mounting urgency, the surgeon is called for, and then the anesthesiologist. Announcement of the code-pink drill sounds throughout the hospital as the team transports Noelle to the operating room. Adding to the challenge, the OR is seven floors down from the OB unit. Throughout it all, Noelle’s anxious voice rings out: “Has somebody talked to my husband? I’m really scared. Are you sure this is the best thing for my baby?”
“This Is Not How I Thought It Would Be”
The intense focus on synchronizing supplies and processes, vital as it is to a successful outcome, may paradoxically neglect the patient’s most important needs. In the midst of briefing physicians, obtaining informed consent, completing the transport, and preparing for surgery, a frightened patient is wondering how her dream birth experience has turned into this frantic whirlwind. In the orientation preceding the drill, Leslee Goetz, MN, RNC-OB, Clinical Nurse Specialist at Swedish First Hill, tells her audience, “One of the major reasons that patients sue is for information. They want to know what happened and they haven’t been able to get answers from their medical providers.” Malpractice claims at Physicians Insurance substantiate that statement. Nationwide, communication and teamwork problems are the most commonly cited root cause of patient injury.2
When a birth outcome differs from the patient’s expectation, the relationship with key people involved in her care can determine whether she resolves the emotional aftermath or files a lawsuit. “This is not how I thought it would be,” laments Noelle in the elevator on her way to the OR. “I understand,” says a nurse, laying a hand on her shoulder, “This is not what we planned. But you’re doing a great job working with us to get your baby delivered. We’re putting on the cautery pad now, as part of a routine safety procedure, and those compression sleeves for your legs are to prevent blood clots. Keep taking deep breaths, Noelle. It won’t be long now.”
Teamwork Doesn’t Just Happen
During the debrief session, teams review the video of their drill. Watching the filmed simulation allows participants to notice lapses in communication and ambiguity in roles that might otherwise have gone unaddressed. Their increased awareness fuels discussion of what worked well and what might work better. Teamwork is born of such collaboration, arising naturally from the mutual recognition of group strengths, as well as the humbling observation of its weaknesses.
Teamwork is also enhanced by well-timed instruction. In one part of the orientation, the anesthesiologist for each drill demonstrates the technique for applying cricoid pressure, and explains the best way for the RN to assist. Nurses are then able to practice cricoid pressure on Noelle with immediate feedback from anesthesia. “Even though everyone involved was skilled at their own piece of the puzzle,” says anesthesiologist Susan Wetstone, MD, “it was challenging to put all our pieces together. The drill I participated in was valuable for us to get practice working together in stressful situations. We found many opportunities to make easy changes that could improve patient care.”
System Improvements
The lessons learned at every one of the debrief sessions are noted by Joyce Miller, RN, Clinical Nurse Manager at Swedish Edmonds, who championed the drills. “We intend to practice and hard-wire the roles,” she says, “so when the emergency occurs, our response will be second nature.” Several improvements suggested at these discussions are already in place. The unit now has a system, led by the charge nurse, for a three-minute debrief after difficult deliveries, and a form to summarize the event. Protocols are also established that empower nurses to transfer a patient to the next level of care without the physician being present. Agreement is unanimous during the debriefs that a vaginal delivery in the OR is preferable to the risks involved in delaying transport.
Additional ideas have sprung from the drills: having a pre-assembled c-section kit on hand in the OR, and utilizing spare moments for surgical preparation, such as administering the sodium citrate or putting on the surgical compression devices. Family practitioner Rachel Hollister, MD, says, “Putting on the SCDs in the elevator is a great use of that time.”
More lessons are gleaned from TeamSTEPPS, an evidence-based system, designed by the Agency for Healthcare Research and Quality (AHRQ) and the Defense Department to improve patient safety through communication skills. Examples include the check-back, in which the receiver of a request confirms that the action is completed, and the call-out, used to communicate with the whole team, but directed at a specific individual to verify that the message will be acted upon.
Can Simulation Improve Outcomes?
A growing number of studies are confirming what the obstetrical staff at all three of our simulation sites sense intuitively: simulation training will indeed improve patient outcomes. In the United Kingdom, teams taught using simulation demonstrated sustained improvement in clinical management.3 Another UK study showed a significant reduction in neonatal injuries following the introduction of simulation training.4
“If we can prevent even one maternal death, these simulations are worth it,” states Susan Rutherford, MD, Medical Director, Women’s and Children’s Services at Evergreen Medical Center. Her experience at our shoulder dystocia simulation training in November convinced her that “you can expect better outcomes, higher morale, and more accurate documentation.” Staff there unanimously reported that the simulation training improved their ability to provide better care for their patients.
Joyce Miller, RN, at Swedish Edmonds Hospital, agrees. “To have a drill of this caliber, this was amazing to us. It really was.”
Physicians Insurance is proud to lead the way with CME aimed at advancing patient safety and health outcomes. A note received recently from Evergreen Hospital provides a clear example:
Following the November day of shoulder dystocia drills, a nurse and provider who attended the training shared a successful delivery of a newborn with a “severe” shoulder dystocia. When she and the provider recognized the situation, they communicated clearly what was occurring and began to perform the maneuvers they had learned during their training. To their extreme delight, the newborn quickly rotated and delivered without any noticeable delay or birth trauma. Following the delivery the provider and nurse had a short debrief where they were able to capture the essential elements of the delivery and record them into the medical record as one shared story.
Physicians Insurance anticipates bringing the program to more hospitals over the next few years, and is seeking to expand simulation training to other specialties. In the meantime, it’s been an honor to collaborate with the Gossman Simulation Center, and with Evergreen, Harrison Silverdale, and Swedish Edmonds hospitals, to further our shared vision of improving health outcomes.
1. Laura Landro, “Delivering Results: Making Birth Safer,” Wall Street Journal, March 28, 2011, R7.
2. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, “Efforts to Reduce Medical Errors: AHRQ’s Response to Senate Committee on Appropriations Questions,” http://www.ahrq.gov/qual/pscongrpt/psini2.htm.
3. L. Birch, N. Jones, P. M. Doyle, P. Green, A. McLaughlin, C. Champney, D. Williams, K. Gibbon, K. Taylor. “Obstetric skills drills: evaluation of teaching methods,” Nurse Educator Today, 2007 Nov; 27(8):915-22.
4. L. Wilson, J. Ash, J. Crafts, T. Sibanda, T. Draycott, “Does Training Reduce the Incidence of Fetal Injury in Cases of Shoulder Dystocia?” Simulation in Healthcare, 2006 Fall: 1(3):185.