Multiprofessional firedrill training in the labour ... - Wiley Online Library

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The Obstetrician & Gynaecologist

10.1576/toag.11.1.55.27469 www.rcog.org.uk/togonline

2009;11:55–60

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Education Multiprofessional ‘fire-drill’training in the labour ward Authors Dimitrios Siassakos / Joanna Crofts / Cathy Winter / Timothy Draycott / on behalf of the SaFE Study Group

Key content: • Regular multiprofessional rehearsals of the management of obstetric emergencies have been recommended since 1997. • In-house training is cheap and associated with improved outcomes. • Teamwork failure is associated with poor obstetric outcome but aviation-based team training is not a panacea: we may need to develop and evaluate obstetricspecific interventions.

Learning objectives: • To comprehend the importance of rehearsals in the labour ward. • To understand the components of successful ‘fire-drills’.

Ethical issues: • Excessive focusing on the processes of training can lead to neglect of teamworking and prevent sustainable differences in outcomes. • Entrenched negative attitudes to risk management processes can reduce the impact of training. Keywords eclampsia / obstetric emergency / shoulder dystocia / simulation training Please cite this article as: Siassakos D, Crofts J, Winter C, Draycott T. Multiprofessional ‘fire-drill’ training in the labour ward. The Obstetrician & Gynaecologist 2009;11:55–60.

Author details Dimitrios Siassakos MSC MRCOG Specialist Registrar in Obstetrics and Gynaecology Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK; and Clinical Fellow in Medical Education Bristol North Academy, Frenchay Hospital, Bristol BS16 1LE, UK

Joanna Crofts BM BS Specialist Registrar in Obstetrics and Gynaecology Taunton and Somerset Hospital, Musgrove Park, Taunton, Somerset TA1 5DA, UK

© 2009 Royal College of Obstetricians and Gynaecologists

Cathy Winter RM Practice Development Midwife Southmead Hospital, Bristol, UK

Timothy Draycott MD MRCOG Consultant Obstetrician and Gynaecologist Southmead Hospital, Bristol, UK Email: [email protected] (corresponding author)

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Introduction and background The Confidential Enquiries into Maternal Deaths in the United Kingdom (CEMD)1–3 have shown that around half of all maternal deaths could have been prevented with better care. The Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have also identified substandard care as a major contributor to fetal and neonatal mortality.4,5 Both enquiries repeatedly highlight the role of inadequate clinical care, as well as poor communication and teamwork within labour ward teams. Poor care has both financial and human costs. In the UK, obstetric claims represent 20% of the cases dealt with by the National Health Service Litigation Authority (NHSLA) but 80% of the costs of claims.6 By 2003, the cost of outstanding NHSLA claims for incidents occurring on or after 1 April 1995 in obstetrics and gynaecology was over £2 billion.7 The situation is mirrored in the USA: a medical insurance liability crisis has negatively affected access to obstetric care in 23 states, with one in seven Fellows of the American College of Obstetricians and Gynecologists reporting that they had stopped practising obstetrics because of the high risk of liability claims.8

concluded that there was little evidence to demonstrate a direct benefit of obstetric emergency training. Since publication of their review, however, there has been an increasing number of reports of the benefits of ‘fire-drills’ in labour wards. In this paper we review the evidence for multiprofessional training and the implications for training provision.

Evidence for the effectiveness of obstetric emergency training Training courses Many obstetric emergency courses have been described; some are multiprofessional, whilst others are aimed at a single discipline. Training can be conducted externally, e.g. Advanced Life Support Training in Obstetrics (ALSO) for healthcare professionals,14 Managing Obstetric Emergencies and Trauma (MOET),14 Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES),15 or within hospitals, e.g. PRactical Obstetric MultiProfessional Training (PROMPT)16 and Training in Obstetric Emergency Scenarios (TOES).17

As a consequence, there has been a shift away from striving for individual technical perfection to better team co-ordination and training. This has been reflected in the recommendations by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives in their report, Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour,9 as well as in the CEMD1–3 and CESDI4,5 recommendations for regular multiprofessional ‘fire-drill’ training in the management of labour ward emergencies. Similar recommendations have been made in the USA.10

Levels of training The gold standard for an effective obstetric training programme is that there are demonstrably improved maternal or neonatal outcomes. Kirkpatrick18 described four levels for evaluating the effect of training programmes (as modified by Freeth et al.):18

Annual drill training of all obstetric and midwifery staff in the management of cord prolapse, vaginal breech delivery, shoulder dystocia, antepartum haemorrhage and severe postpartum haemorrhage is also mandated by the Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical Risk Management Standards in England,11 the Clinical Negligence and Other Risks Scheme (CNORIS) in Scotland12 and the Welsh Risk Pool.13 The NHS has schemes in which maternity hospitals with a high standard of training, guidelines and audit are rewarded with reduced insurance premiums.

Level 1: reaction (satisfaction) MOSES is a UK-based course that uses simulation of obstetric scenarios at a simulation centre to teach teamworking skills. Feedback suggests that participants feel better equipped to deal with obstetric crises after training.15

In 2003, however, a systematic review1 of obstetric emergency training in the UK identified descriptions of just six obstetric emergency courses. Only four papers described how the training programmes had been evaluated — all subjectively. Finding no objective evaluation, the authors 56


1 Reaction — satisfaction of learners 2 Learning — factual and applied knowledge, attitudes 3 Behaviour — patient care and satisfaction 4 Results — patient outcomes and infrastructural/organisational changes

A significant improvement in caregivers’ own comfort with managing obstetric emergencies before, immediately after and 1 year following participation in an ALSO course has been reported.19 Positive feedback has also been reported by junior doctors after attending an ALSO course in the USA.20 The Yorkshire Simulated Delivery Suite (SiDeS) management course is a 1-day training course for junior doctors. It covers teamwork, prioritisation, patient management, discussion of case reports © 2009 Royal College of Obstetricians and Gynaecologists

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from the UK confidential enquiries and a simulated shift on a delivery suite. All 30 doctors attending one such course rated each component of training as good or very good.21

Moreover, a change in attitudes after training has been shown. In one unit there was a reduction of midwives’ requests for sick leave by 45% after the introduction of obstetric emergency training.28

In the USA the Harvard Center for Medical Simulation has a Labor and Delivery Crisis Resource Management course,22 a 6-hour, simulation-based training course emphasising co-operation and communication within multidisciplinary labour and delivery care. Nineteen participants all felt that it improved teamwork and communication and would prevent adverse outcomes.23

Level 3: behaviour (skills, patient care) The SaFE study also evaluated the clinical performance of individuals and teams managing simulated obstetric emergencies before and 3 weeks, 6 months and 12 months after training. Individual management of shoulder dystocia improved following training, with 43% of staff able to complete a delivery successfully before training rising to 83% after training.29 There was a significant additional benefit of training on highfidelity compared with low-fidelity mannequins.29 Extra teamwork training did not confer any additional benefit.30

Although most studies14,15 report improvement in confidence after training, in a recent study of 148 trainees,24 84% of those who had declared being confident of their competence in managing obstetric emergencies before training retracted their statements after being tested in simulated scenarios. Level 2: learning (knowledge and attitudes) An improvement in standardised objective scenario-based structured questions set on the first and third days of the 3-day MOET training course has been reported.25,26 The assessments were undertaken as part of the training course and were completed by nine obstetricians in Bangladesh25 and eight in Armenia.26 The Simulation and Fire-drill Evaluation (SaFE) study27 is a large randomised controlled trial recently completed in the southwest of England. The study was commissioned by the Department of Health to investigate methods of multiprofessional obstetric emergency training. It evaluated the effect of training in local hospitals versus training at a central simulation centre and the effect of an additional day of specific teamwork training. One hundred and forty staff (95 midwives and 45 doctors) were randomly recruited from six hospitals across the southwest of England. Each participant was randomised to one of the four following multiprofessional obstetric emergency courses:

• 1-day course within their own hospital • 2-day course, with teamwork training, within their own hospital • 1-day course at a central simulation centre • 2-day course, with teamwork training, at a central simulation centre.

Participants completed a multiple-choice questionnaire consisting of 185 questions before and after training. Overall, there was a significant increase in knowledge after training, without any effect of either the locality of training or the inclusion of additional teamwork training.27


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In the 24 multiprofessional teams that managed a simulated eclampsia scenario before and after SaFE study training, there was an increase in completion of basic tasks (87% before, 100% after) and those tasks were completed more quickly (55 versus 27 seconds). The magnesium loading dose was administered by 61% of teams pre-training and by 92% post-training. In teams that commenced magnesium sulphate both before and after training, the median time to administration was significantly reduced after training from 389 to 273 seconds. Training at the simulation centre was not associated with additional improvement compared with local hospital training. Teamworking generally improved (the median global score rose from 2.5 to 4.0) but, again, there was no added benefit from additional specific teamwork training. The SaFE study also investigated the effect of obstetric emergency training on care (communication, safety and respect) as perceived by a patient-actor in the simulated scenarios. There was a significant improvement in scores for all scenarios. Perceptions of safety and communication during postpartum haemorrhage were significantly improved following training with patient-actors in local hospitals, compared with training with computerised full body simulators at the simulation centre. Level 4: patient outcomes Reduction in the rates of low 5-minute Apgar scores (from 86.6 to 44.6 per 10 000 births [P0.001]) and hypoxic ischaemic encephalopathy (from 27.3 to 13.6 per 10 000 births [P0.032]),31 as well as brachial plexus injury (from 9.3% to 2.3%, relative risk 0.31, 95% CI 0.13–0.72),32 have been reported following the introduction of multiprofessional obstetric training at Southmead Hospital in Bristol, UK. Training was conducted within the local maternity unit by a multiprofessional team of midwives, obstetricians and anaesthetists, with all midwives 57

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and obstetricians attending training annually. A similar effect was described in other units33,34 with regular obstetric fire-drills. The Beth Israel Deaconess Medical Center in Boston, USA, initiated crew resource management (CRM) team training for all maternity staff, following the outcome of a comprehensive root cause analysis of a case involving a stillbirth and peripartum hysterectomy.35 Training included 4 hours of classroom instruction on CRM, which was reinforced by physician and nurse ‘coaches’ during routine clinical work. Wide-ranging system changes were introduced to the maternity department at the same time. Since the introduction of training, there has been a 25% overall reduction in adverse obstetric events and a 52% reduction in malpractice claims, leading to a $4.9 million reduction in reserve money allocated.36 As with the Southmead data, it is difficult to prove causal association for the intervention and improvement in outcome. The authors note, however, that the introduction of CRM training was the main intervention over this period and they believe that causality is highly likely. In a recent randomised controlled trial (MedTeams Labor and Delivery),37 however, similar CRM methods failed to achieve improvement in either real-life outcome or process measures when applied in labour ward settings.

Implications for training There have been no prospectively collected data on obstetric outcomes after the introduction of training in maternity units. There is evidence, however, to suggest that staff feel more confident in the management of obstetric emergencies and that levels of staff sickness are reduced after training. Multiprofessional obstetric emergency training improves knowledge, skills, teamworking and patient-actors’ perception of their care. In some hospitals it has been associated with improvements in real-life clinical outcomes. Multiprofessional obstetric emergency training is vital. Surveys of staff before training have shown some lack of confidence in their ability to manage emergencies, whilst evaluations have identified deficiencies in staff knowledge and skills. Reports of better clinical outcomes have all been associated with training within local hospitals, perhaps because it is important to train 100% of staff to achieve improvement. Training within local hospitals may also have added advantages, i.e. addressing specific local issues and prompting infrastructural change but this can be difficult to achieve on a busy labour ward. It is always difficult to discuss cases from within the department and in our unit we share anonymised cases with other 58


units in the South West Obstetric Network to facilitate discussion. External training courses may have other advantages: they are not liable to interruption because of clinical matters and they may be more suited to training the labour ward leads—the senior midwives and obstetricians—in more advanced techniques for managing obstetric emergencies than local training. Local training is likely to be more cost-efficient than external training: it has been estimated that in a large UK obstetric unit it would cost £40 000 per year to finance in-house training for all midwifery staff, compared with £210 000 per year for external courses.32 Training 100% of staff can also have huge financial implications for healthcare Trusts: a medium-sized obstetric unit can reduce their CNST insurance premiums by up to £500 000 per year at level 3. Evidence for the effect of teamwork training is mixed: some studies suggest that teamwork training is important per se, whilst others suggest that simply training in multiprofessional teams is as effective as a whole day of specific teamwork training. There has been a trend in recent years to adopt teamwork training principles from the aviation industry. Most maternity caregivers, however, would recognise that obstetric emergencies differ from those on aeroplanes: training methods that are effective in the aviation industry may not be effective in obstetrics. The woman and her family are central to any obstetric emergency (in contrast with an aviation emergency, where it is unlikely that a passenger will be in the cockpit). During an obstetric emergency the ‘person behind the patient’ should not be forgotten and training should reflect this. An investigation of claims in obstetrics and gynaecology reported that communication problems occurred in about one in seven cases and that they adversely affected patients’ and relatives’ satisfaction and provoked concern for their safety.38 Data from the SaFE study39 suggest that obstetric emergency training improves women’s perception of their care during simulated emergencies and that perception can be further improved by training using actors rather than computerised mannequins. The CNST recommends annual training for all staff. In shoulder dystocia management the majority of staff who had training in delivery could still achieve delivery 12 months later; therefore, for shoulder dystocia this recommendation appears adequate for the majority. Some obstetric emergency courses require staff to pass a test at the end, whilst others do not. Interestingly, staff were © 2009 Royal College of Obstetricians and Gynaecologists

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not formally assessed in the training courses associated with improvements in real clinical outcomes,31 suggesting that formal testing of participants may not be necessary. The posttraining evaluation of shoulder dystocia management during the SaFE study, however, identified those participants who had not gained the necessary skills to manage severe shoulder dystocia. A few minutes of individualised training meant that the majority learned how to achieve delivery successfully and that they retained those skills for at least 12 months.40

Summary In hospitals, multiprofessional obstetric emergency training has been part of national recommendations and standards for more than 10 years but there has been, until recently, little evidence on how training should be performed or its effectiveness. Inadequate management of obstetric emergencies may reflect that staff are not incompetent but inadequately trained. Staff working in maternity units deserve the best possible training so that, whenever emergencies do occur, mothers and their babies receive the best possible care. The essential components of effective emergency training are summarised in Figure 1. References 1 Drife J, Lewis G, editors. Why Mothers Die. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994–96. London: The Stationery Office; 1998. 2 Lewis G, Drife J. Why Mothers Die 1997–1999: The Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2001. 3 Lewis G; CEMACH. Why Mothers Die 2000–2002. The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004. 4 Maternal and Child Health Research Consortium. CESDI 5th Annual Report—Focus Group Shoulder Dystocia. London: MCHRC; 1996. 5 Maternal and Child Health Research Consortium. CESDI 6th Annual Report—The ‘4kg and over’ Enquiries. London; MCHRC; 1997. 6 Select Committee on Health. Memorandum by Action forVictims of Medical Accidents. London: United Kingdom Parliament; 2003. 7 National Health Service Litigation Authority. A journal for practising clinicians. NHSLA Journal 2003;2:4. 8 American College of Obstetricians and Gynecologists. ACOG’s Red Alert on Ob-Gyn Care Reaches 23 States. [Press release.] Washington DC: ACOG; 2004. 9 Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College of Midwives, Royal College of Paediatrics and Child Health. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press; 2007. 10 The Joint Commission. Preventing infant death and injury during delivery. Sentinel Event Alert Issue #30. 21 July 2004 [www.jointcommission.org/ SentinelEvents/SentinelEventAlert/sea_30.htmhttp://www.jointcommissi on.org/SentinelEvents/SentinelEventAlert/sea_30.htm]. 11 NHS Litigation Authority. Clinical Negligence Scheme forTrusts: Maternity. Clinical Risk Management Standards [www.nhsla.com/ RiskManagement/CnstStandards/]. 12 Clinical Negligence and Other Risks Indemnity Scheme. Revised Risk Management Standards V4/2003, Standard 9 [www.cnoris.com]. 13 Children’s Health & Social Care Directorate, Welsh Assembly Government. Standard 5, Maternity. National Service Framework for Children, Young People and Maternity Services in Wales. Cardiff: Welsh Assembly; 2005 [www.wales.nhs.uk/sites3/Documents/441/EnglishNSF_ amended_final.pdf]. 14 Black RS, Brocklehurst P. A systematic review of training in acute obstetric emergencies. BJOG 2003;110:837–41. doi:10.1111/j.1471-0528.2003.02488.x 15 Johannsson H, Ayida G, Sadler C. Faking it? Simulation in the training of obstetricians and gynaecologists. Curr Opin Obstet Gynecol 2005;17: 557–61. doi:10.1097/01.gco.0000188726.45998.97 16 DraycottT, Winter C, Crofts J, Barnfield S. PRactical Obstetric Multiprofessional Training (PROMPT) Trainer’s Manual. London: RCOG Press; 2008. 17 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives. The Clinical Learning Environment and Recruitment. Report of a Joint Working Party. London: RCOG Press; 2008 [www.rcog.org.uk/ resources/public/pdf/ClinicalLearningWPR2007.pdf].


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• Management need to support changes. • There should be institution-level incentives to train (safety culture).

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Figure 1

The essential components of effective obstetric fire-drills

• The organisational infrastructure should support regular drills. • Staff should be encouraged to participate in developing and running courses. • Annual attendance by 100% of staff should be mandated and confirmed. • Costs should be kept to a minimum by providing training in-house. • Actors and realistic training tools should be used. • Training should be interprofessional: different grades of each professional group and ancillary staff, where relevant, should be included. • Teamwork principles should be integrated into the drills. • Formal assessment may not be necessary—training can be fun. • Clinical results should be monitored and fed back to staff.

18 Freeth D, Hammick M, Koppel I, Reeves S, Barr H. A Critical Review of Evaluations of Interprofessional Education. Occasional Paper No. 2. [MSc thesis.] London: Higher Education Academy; 2002 [www.health. heacademy.ac.uk/publications/occasionalpaper/occasionalpaper02.pdf]. 19 Taylor HA, Kiser WR. Reported comfort with obstetrical emergencies before and after participation in the advanced life support in obstetrics course. Fam Med 1998;30:103–7. 20 Flora RF, Rich M, Siegfried J, Fanning J. The ALSO course for use in patient safety and as a competency-based orientation for interns. Obstet Gynecol 2006;107 Suppl 4:77S–8S. 21 Jha V, Kaufmann S, Duffy S. Simulated delivery suite (SiDeS) management course: an innovative method for future training in obstetrics. Innovations in Education and Teaching International 2003;40:379–85. doi:10.1080/1470329032000103843 22 The Commonwealth Fund. Case study: the Harvard Center for Medical Simulation’s Labor and Delivery Crisis Resource Management Course. March 2005 [www.cmwf.org/tools/tools_show.htm?doc_id=270669]. 23 Raemer DB, Morris G, Gardner R, WalzerTB, Beatty T Jr, Mueller KB, et al. Development of a simulation-based labor & delivery team course. International Meeting on Medical Simulation, 2003, USA [www.anestech.org/media/Publications/IMMS_2003/sta14.html]. 24 Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007;109;1295–300. 25 Johanson R, Akhtar S, Edwards C, Dewan F, Haque Y, Jones P. MOET: Bangladesh—an initial experience. J Obstet Gynaecol Res 2002;28:217–23. 26 Johanson RB, Menon V, Burns E, Kargramanya E, Osipov V, Israelyan M, et al. Managing Obstetric Emergencies and Trauma (MOET) structured skills training in Armenia, utilising models and reality based scenarios. BMC Med Educ 2002;2:5. doi:10.1186/1472-6920-2-5 27 Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 2007;114:1534–41. doi:10.1111/j.1471-0528.2007.01493.x 28 Ellis D, Crofts JF, Hunt LP, Read M, Fox R, James M. Hospital, Simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol 2008;111:723–31. 29 Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol 2006;108:1477–85. 30 Crofts JF, Bartlett C, Ellis D, Winter C, Donald F. Hunt LP, et al. Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors. Qual Saf Health Care 2008;17:20–4. doi:10.1136/qshc.2006.021873 31 Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006;113:177–82. doi:10.1111/j.1471-0528.2006.00800.x 32 Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008;112:14–20. 33 Scholefield H. Embedding quality improvement and patient safety at Liverpool Women’s NHS Foundation Trust. Best Pract Res Clin Obstet Gynaecol 2007;21:593–607. doi:10.1016/j.bpobgyn.2007.02.005 34 Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclampsia drills. Qual Safe Health Care 2004;13:127–9. doi:10.1136/qhc.13.2.127 35 Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA 2005;294:833–40. doi:10.1001/jama.294.7.833 36 Pratt SD, Sachs BP. Team training: classroom training vs. high-fidelity simulation. Agency for Healthcare Research and Quality [www.webmm. ahrq.gov/perspective.aspx?perspectiveID=21]. 37 Nielsen PE, Goldman MB, Mann S, Shapiro DE, Marcus RG, Pratt SD, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol 2007;109:48–55.

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38 White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 2005;105:1031–8. 39 Crofts JF, Bartlett C, Ellis D, Winter C, Donald F. Hunt LP, et al. Patient-actor perception of care: a comparison of obstetric emergency training using

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manikins and patient-actors. Qual Saf Health Care 2008;17:20–4. doi:10.1136/qshc.2006.021873 40 Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Management of shoulder dystocia: skill retention 6 and 12 months after training. Obstet Gynecol 2007;110:1069–74.
