1. Simulation in Obstetrics Dr. Renee Bobrowski Debbie Ketchum, BSN, RNC, MAOM Kelly Wilson, RNC

2. Getting to Know YOU How many of you are actively involved in OB simulation? How many of you lead teams for simulation? How many of you have been to other conferences regarding this subject? How many of you have had to be the OB patient for Simulation?

3. Objectives Why do we do it? What it simulation? Clinical value in medicine How do we do it…

4. THEWHYTHEWHY

5. Why do we need a new training method? Suburban Hospital Staff #s Obstetricians 81 L&D Nurses 50 Anesthesiologists 16 NNPs 12 Scrub Techs 14 CRNAs 35 How many C/S teams are possible with these staff numbers? 381 Million!

6. The Number One Risk to Safety? Variability!

7. What is Medical Simulation Use of a device or series of devices along with clinical personnel, – To emulate a real patient care situation or environment – For the purpose of training and evaluation It is not just “technology” – It is a proven “technique” to train healthcare personnel without risk to the patient or members of the clinical team Provides the opportunity for clinicians to… – Practice routine as well as low incidence, high risk events THEWHATTHEWHAT

8. Simulation Ancient Greeks used to illustrate philosophical concepts Records of its use in 1600s for teaching midwives – Basket and leather fragments in shape of a pelvis Used today in a variety of industries – Airline industry has led the way Substantial decline in accidents from 1980s onward Crew resource management – Error management – Capability to detect, avoid, trap or mitigate human error and therefore prevent fatal accidents

9. Simulation Simulation allows us to expose and correct weaknesses, vulnerabilities and the potential for error before it causes harm

10. Simulation Provides opportunities – Gain skills when real world training is expensive or dangerous – Experience – Refine and refresh skills Currently used in multiple disciplines – Anesthesia – General and trauma surgery – Emergency medicine – Obstetrics and pediatrics – And the list grows…….

11. Simulation Training Opportunity to practice: – Technical skills Hands on procedures – deliver the baby, give medication – Cognitive skills Critical thinking Decision making – Behavioral skills Interpersonal interactions It is a team sport!!

12. Simulation in Obstetrics Endless possibilities – Low-frequency, high acuity events are perfect for simulation Eclampsia, Shoulder dystocia, Hypertensive Crisis – But it is equally effective for common, everyday events Ideally multidisciplinary team performing drills – Include anesthesia, neonatology/peds staff and providers – Combine disciplines as with Obstetric Trauma cases Most important is post-scenario debriefing – Participants explain, analyze and synthesize their actions

13. Possible Perinatal Scenarios Maternal – STAT C/Section – Shoulder dystocia – Difficult maternal airway – PP Hemorrhage – Amniotic fluid embolism – High regional block – Seizure – Anaphylaxis – Fire in the OR – D &C’s Neonatal – Neonatal resuscitation – Hypovolemia – Meconium – Premature birth – Fetal anomalies Neural tube defect Diaphragmatic hernia Abdominal wall defect

14. What Simulation Does Best Provides a safe environment – Mistakes are tolerated – Appropriate responses learned and then practiced Identify system-based issues and staff responses that can be improved in response to critical clinical events – Impact of simulation training can be monitored by tracking clinical outcomes Reduce malpractice premiums through incentive programs in risk-reduction

15. What Simulation Does Best Benefit communities through education of paramedics, EMTs and critical access hospitals, Helps build confidence, communication techniques, and skills in our newer staff

16. Getting a Program Started Core group of committed staff and providers – Need a champion! (Physician/Provider and Nurse) – It takes time to develop and run a program Need administrative support – and that includes financial! – You will see a return in investment – e.g. decreased insurance premiums Focus on the simple things first – Think about clinical issues that have been challenging “Near misses” – Consider processes that could use improvement Time it takes to get a CS team together and patient to OR for stat CS THEHOWTHEHOW

17. Getting a Program Started In Situ™ Simulation Experiential learning Application Test for gaps ID ERROR Just Culture™ Principles of risk Accountability Focus on Behavior MANAGE ERROR TeamSTEPPS ™ Define the team Use the tools Coach to sustain MITIGATE ERROR High Reliability High Reliability Riley, W, Davis, S, Miller, K, Mccullough, M. A Model for developing high- reliability teams. Journal of Nursing Management. July 2010 p 556-563.

18. Getting a Program Started ® Team Strategies and Tools to Enhance Performance and Patient Safety Evidence based Improves outcomes Increases satisfaction Decreases harm

19. Getting a Program Started SKILLS Situational Awareness Standardized Language (ex: SBAR) Closed-Loop Communication Shared Mental Model “US” TOOLS SBAR NICHD Language Code C-section Stop the line ®

20. Getting a Program Started Write up a short script for the scenario Provide a Brief with the Ground Rules of Safety/Trust – Let the group manage the situation and play it out Allow mistakes to be made No coaching – just give clinical information to keep the simulation moving – e.g. patient response to a medication or procedure – Have specific tasks in mind that should be accomplished Medical procedure, communication, staff interaction Review what was and was not done when you debrief

21. Getting a Program Started Don’t need fancy stuff – Do the simulation where the care occurs or improvement is needed L&D, the OR, the ED – Use staff to act as patients – Appropriate size doll for term and preterm babies Neonatal resuscitation – Video tape for debriefing

22. Who is Noelle? Variety of mannequins – Hemi-pelvis – Noelle – Baby Hal Clinical scenarios programmed into the simulator – Noelle speaks – Vital signs and fetal heart rate tracing change as the scenario unfolds – Perform cervical exams, follow labor progress and deliver baby Breech delivery Shoulder dystocia

23. Debriefing is Where the Learning Happens 1.What went well and “why”? 2.What could have gone better and “why”? 3.What would I do differently next time? Review the Types of Comments Communication and Teamwork Process Improvement “Simisms” Clinical Care Review Individual Communication & Teamwork Skills Situational Awareness “ME” Standardized Language (ex: SBAR) “YOU” Closed-Loop Communication Shared Mental Model “US”

24. debrketc@sarmc.org renebobr@sarmc.org

25. Let’s Have Some Fun!