Acute obstetric emergency drill in England and Wales: a survey of practice
Dr P. Brocklehurst, National Perinatal Epidemiology Unit, Oxford University, Old Road Campus, Old Road, Headington, Oxford, OX3 7LF, UK.
Multidisciplinary training for obstetric emergencies is an issue of current interest and debate in the UK. This paper presents a survey of current practice in obstetric emergency drill training in England and Wales. A wide range of training methods and opinions about these methods are demonstrated in this survey. There is much interest in improving the management of obstetric emergencies and this is to be encouraged. However, reliable methods to assess and thereby optimise methods are urgently required in order that women and their babies can realise the maximum benefit from these complex interventions.
Multidisciplinary training for obstetric emergencies is an issue of current interest and debate. Obstetric emergency drill has been recommended by the Confidential Enquiry into Maternal Deaths1 (CEMD) and the Confidential Enquiry into Stillbirths and Deaths in Infancy2 (CESDI) based in the UK (which have now become part of the Confidential Enquiry into Maternal and Child Health [CEMACH]). The Clinical Negligence Scheme for Trusts3 (CNST) in England requires that ‘all relevant staff participate in annual skills drill’ as part of qualification for Level 2 status. The level conferred by the CNST affects the amount of medical negligence insurance a hospital is required to pay. We recently published a systematic literature review of training for obstetric emergencies,4 which demonstrated that a variety of training methods, including drill training, have been described but few have been evaluated to determine their effect on the management and outcome of obstetric emergencies.
As emergency drill is being widely recommended in the UK, we felt that a survey examining current practice in obstetric emergency training was appropriate. Our aim was to ascertain whether labour wards in England and Wales are conducting drills, and if so, how they are organised and evaluated. We defined emergency drill as scenario-based training in obstetric emergencies conducted in ‘real time’ in the normal working environment, without the prior knowledge of the staff involved. This type of training is sometimes called ‘fire drill’. The aim of such drill is to test local systems and protocols for responding to emergencies, as well as to test professional teamwork and individual skills and knowledge.
In February 2003, we sent a postal questionnaire to all maternity units in England and Wales, using a database of addresses held at the National Perinatal Epidemiology Unit.
The questionnaire asked whether obstetric emergency drill was being undertaken in that unit and whether there was any written information available about it. We requested the name of a contact person with whom we could conduct a telephone interview. A second round of questionnaires was sent out in April 2003 to those who had not replied initially.
Our aim was to conduct a telephone interview with a representative from each of the units that agreed to be contacted. These interviews were carried out between April and December 2003. Structured interviews were conducted to determine whether drills were currently being run and for how long they had been established. We asked how frequently the drills occurred, which staff were involved and which emergencies were being covered. We also asked who assessed the drills and how assessment and feedback to staff were carried out. If drills were not being run, we asked if they were being planned. The interviews were undertaken by two obstetricians (ERA and RSB) and a structured data collection form was completed during the telephone interview.
Postal questionnaires were sent to 246 delivery units in England and Wales (obstetric-led and midwifery-led). Five of these units had closed or amalgamated with another unit leaving a total of 241 units. Of these, 228 units (95%) returned the questionnaire. Twelve units (5%) declined to be contacted by telephone of which eight stated that they were currently conducting drills.
Of the 216 units who agreed to a telephone interview, the named representative was not contacted in 31 centres (14%) despite several attempts. Telephone interviews were therefore conducted with the representatives of 185 delivery units, or 86% of the units which agreed to be contacted and 77% of all delivery units in England and Wales.
Of the 185 units that were interviewed, 95 centres (51%) were conducting ‘fire drills’. The emergencies covered in these drills were massive obstetric haemorrhage, shoulder dystocia, eclampsia, maternal and neonatal resuscitation, cord prolapse and breech delivery. The characteristics of these drills are shown in Table 1.
Table 1. Characteristics of fire drills.
|Staff involved in drills|
|Multidisciplinary (e.g. midwives, obstetricians, paediatricians, anaesthetists, health care assistants, theatre staff)||84 (88)|
|Adjuvant services (e.g. laboratories, hospital switchboard, porters)||75 (79)|
|Resuscitation officer||7 (7)|
|Assessment and feedback after drills|
|Group discussion||95 (100)|
|Written report||51 (54)|
|Frequency of drills|
|At least twice a month||11 (12)|
|Three or four times a year||50 (53)|
Ninety units (49%) were not conducting drills but 26 of these (29%) stated that they were developing them. Most of those developing drills did not yet have a date for implementing them. The reasons for not conducting fire drills are summarised in the qualitative results.
One hundred and fifty-one of the units that we interviewed were asked whether they conducted training for obstetric emergencies other than fire drills. One hundred and forty-nine (99%) of these said that they conducted regular classroom-based emergency training sessions instead of, or in addition to, fire drills. The content of these sessions varied and is described in the next section under ‘Other training for obstetric emergencies’.
Qualitative themes from the interviews
A variety of opinions of obstetric emergency training were expressed in the interviews, with different methods of training appearing to be more or less acceptable in different maternity units. We have grouped the spontaneous comments that people made about obstetric emergency training into five themes to convey the breadth of ideas expressed about the different methods.
Reasons for not running fire drills
Seven units said that they had either not started fire drills or had stopped running them because staff found the process threatening and stressful or not helpful. In these units it was thought that scenario-based classroom teaching was a more effective way to learn than when staff felt they were ‘on trial’. Some units said they had introduced scenario-based training in the classroom before starting ad hoc drills in order to boost staff confidence and demonstrate what was expected in the drill practice. It was not clear whether this plan had been successful. Some birth centres, which were only staffed when women were in labour, found that classroom teaching reached more midwives more efficiently. Other units mentioned that they had difficulty arranging multidisciplinary training. Reasons given for this included finding mutually convenient times, historically separate training programmes for midwives and doctors, a perceived lack of interest in multidisciplinary training in some centres and a mismatch in the amount of time provided for study for doctors and midwives.
Difficulties encountered when running fire drills
Problems raised during the interviews included the difficulty of running drills in busy units, many of whom were struggling to recruit and retain midwifery staff. Some units were concerned that service provision could be adversely affected while drills were being conducted. More than one centre said that drill practice and other multidisciplinary training had only become possible after the appointment of a dedicated Professional Development or Risk Management midwife. Many centres pointed out that planning and conducting fire drills demanded a substantial amount of time and energy and that each drill may only include a few staff. With mandatory classroom-based study days, it was easier to ensure that all staff received training in obstetric emergencies on an annual basis. These centres also felt that it was easier for staff to concentrate on learning when they were not being distracted by the demands of the service. The number of study days available to midwifery staff varied from none to seven days annually in the units to whom we spoke.
Positive aspects of fire drill
Many centres said that staff had reported increased confidence in emergency teamwork as a result of the drills. Many also said that they tried to make the drill training constructive and fun so that it was perceived as a positive learning experience and not a threat. One unit overcame initial reluctance to participate in drills and ran a regular programme in which volunteers from the Maternity Services patient liaison group played patients and relatives and which people enjoyed learning from. Some units produced an anonymised written report detailing the strengths and weaknesses observed in a particular drill and including recommendations for future practice. The report was circulated to the staff involved, the wider unit (including anaesthetic, paediatric and portering staff), the labour ward forum and the risk management group. Individual feedback was given privately where necessary. A number of units reported improvements as a result of drill training such as better physical organisation of emergency equipment on labour ward, more conveniently located telephones or better knowledge among staff of the location of the eclampsia box or defibrillator. One unit mentioned the development of laminated protocols for the management of emergencies which were kept in every delivery room. Some units described the perceived benefits of multidisciplinary training including midwives, doctors, health care assistants, porters, theatre staff and adjunctive services such as the hospital switchboard. They felt that by training together it was more obvious how the team would work together in a real emergency. One unit said that the health care assistants had become adept at note-taking and recording the timing of events while the rest of the team were dealing with the emergency.
Other training for obstetric emergencies
A large number of centres told us about training that was run in addition to, or as an alternative to, fire drills. All the units that we asked had classroom-based obstetric emergency training similar to ALSO (Advanced Life Support in Obstetrics: http://www.also.org.uk) or MOET (Managing Obstetric Emergencies and Trauma: http://www.alsg.org/main_MOET) training. About half of this training was reported to be multidisciplinary. Some centres mentioned that sending staff on external courses such as ALSO was expensive and time consuming and therefore the teaching was arranged in-house once an adequate number of senior staff had been trained externally. A number of centres mentioned in-depth clinical incident reporting and debriefing of staff after real emergencies as a method of learning from experience. Some units mentioned daily debriefing and teaching sessions on labour ward run by a senior obstetrician or midwife. The care of the women admitted during the previous 24 hours was discussed with midwives, obstetricians, anaesthetists, paediatricians and theatre staff. A minority of units had regular access to simulation centres such as the Bristol Simulation Centre for obstetric emergency training (http://www.bris.ac.uk/Depts/BMSC/).
Evaluation of training for obstetric emergencies
Current studies attempting to evaluate different forms of training appear to be few. There is one on-going study prepared by the South West Obstetric Network and funded by the Department of Health Patient Safety Research Programme called the Simulation and Fire-drill Evaluation (SAFE) Study [Maureen Harris, South West Obstetric Network, personal communication]. Phase 1 of this study aims to develop methods and tools to evaluate the effect of simulation centre and fire drill interventions for the management of acute obstetric emergencies. This includes assessing the knowledge and skills of the staff managing obstetric emergencies, as well as assessing the teamwork involved. In phase 2, the plan is to randomise staff to different forms of training for emergencies. There is also a study on-going in Arrowe Park Hospital to compare the results of ‘real-time’ scenario-based training with classroom teaching [Linda Birch, Senior Practitioner, personal communication]. Apart from these two, we did not identify any centres attempting to evaluate the outcome of different types of emergency training except by asking for feedback on the process from the staff involved.
Training for labour ward emergencies is being widely discussed in obstetric units in the UK. Half of the centres that we spoke to in England and Wales were conducting ‘fire drills’ to practice dealing with obstetric emergencies. A number of units mentioned introducing drills in response to reports from the Confidential Enquiry into Stillbirths and Deaths in Infancy, the Confidential Enquiry into Maternal Deaths and the Clinical Negligence Scheme for Trusts. A recent study published in the British Medical Journal described the use of drill training for obstetric emergencies.5 This study concluded that: ‘repetition of drills in our unit has improved the care of simulated patients with eclampsia. In subsequent drills patient management has followed evidence based practice, with an enhanced level of efficiency. Staff are summoned faster, the resuscitation process is better organised, and drugs are prepared and administered more quickly’. The authors did not examine the management and outcome of real patients with eclampsia after drill practice. There are a variety of possible training methods for obstetric emergencies. We have explored multidisciplinary ‘real-time’ fire drill practice on labour ward in this survey. The potential advantages of fire drills include local teams learning how to respond to emergencies in a local setting. Fire drills are also accomplished in work time and can involve all relevant staff rather than a self-selected group. Potential disadvantages of fire drills are the amount of time needed to organise and run them on busy labour wards and the fact that some people find them intimidating and therefore not conducive to learning.
Classroom-based teaching may involve lectures on the management of emergency situations. In addition, it may involve practical scenarios with models or volunteers acting as the patient. These scenarios can be run in real time by the group undergoing training and assessed against standard protocols. Advantages of local dedicated teaching sessions may include protected time being provided, regular attendance verified more easily and staff can concentrate on learning without the distractions of the working day. Disadvantages include training in a less realistic situation than labour ward, the difficulties of providing study leave to all the staff involved and finding enough local people to teach at these sessions.
National courses such as the MOET and ALSO courses use scenario-based training. Simulation centres use sophisticated facilities and computer-operated mannequins to provide training in medical emergencies. These teaching methods provide experienced instructors and dedicated teaching time, and can provide standardised teaching to a consistent standard. The disadvantages of this approach are that national courses can be expensive and travelling to them takes time and money. It is unlikely that all staff would be able to attend such courses and they are not able to teach about local issues.
As a provider, choosing which method of training to implement is not straightforward. There is very little published evidence examining which training methods lead to improved outcomes for women and babies, as well as improved confidence and competence for the staff caring for them. Other issues are also important such as which methods can be instituted within the constraints of the service and which will be cost effective. The SAFE Study has been established to try and develop outcome measures for different models of training.
The randomised controlled trial is the gold standard for evaluating health care interventions. Trials are also used in education and the Campbell Collaboration aims to increase this evidence base.6 A randomised controlled trial examining different methods of training for obstetric emergencies is conceivable and our survey suggests that there is currently a window of opportunity to study the introduction of fire drills. Half of the delivery units that we interviewed already run fire drills and another 14% were developing them. This suggests that this intervention is being introduced widely but it has not been evaluated in the context of substantive outcome measures. If units not currently running fire drills were randomised to introduce drills in a stepwise manner, then the intervention would gradually be introduced across all units while the outcomes were examined. An example of a simple study looking at the incidence of low Apgar scores in neonates after a programme of staff training was reported in abstract in the Journal of Obstetrics and Gynaecology in 2003.7 Outcome measures could include questionnaires of staff confidence, although this may not translate into improved patient outcomes. Outcomes could also be measures of adherence to pre-established protocols and measures of patient outcome. However, maternal and neonatal outcomes could be difficult to compare between units because the incidence of serious adverse outcomes such as perinatal asphyxial encephalopathy or the admission of women to intensive care is fortunately extremely low.
There is much current interest in improving the management of obstetric emergencies and this is to be encouraged. However, reliable methods to assess and thereby optimise training methods are urgently required in order that women and their babies can realise the maximum benefit from these expensive and complex interventions.
This work was requested by the Department of Health Patient Safety Research Programme.