The active components of effective training in obstetric emergencies
D Siassakos, Research SpR in Obstetrics and Gynaecology, Southmead Hospital, and Clinical Lecturer (Hon) in Medical Education, North Academy, University of Bristol, Bristol, UK. Email email@example.com
Confidential enquiries into poor perinatal outcomes have identified deficiencies in team working as a common factor and have recommended team training in the management of obstetric emergencies. Isolated aviation-based team training programmes have not been associated with improved perinatal outcomes when applied to labour ward settings, whereas obstetric-specific training interventions with integrated teamwork have been associated with clinical improvements. This commentary reviews obstetric emergency training programmes from hospitals that have demonstrated improved outcomes to determine the active components of effective training. The common features identified were: institution-level incentives to train; multi-professional training of all staff in their units; teamwork training integrated with clinical teaching and use of high fidelity simulation models. Local training also appeared to facilitate self-directed infrastructural change.
Giving birth is a natural process, but the transition from a routine to an emergency situation can occur rapidly and unexpectedly. At least 8% of all labours are associated with an adverse outcome.1 Enquiries into suboptimal outcomes have identified common errors: confusion in roles and responsibilities, lack of cross-monitoring, failure to prioritise and perform clinical tasks in a structured coordinated manner, poor communication and lack of organisational support.2,3 As a consequence, there has been a shift away from individual responsibility towards improved team working.
The aviation industry has used Crew Resource Management (CRM) programmes to improve team working, but when isolated CRM training was introduced in obstetrics, it did not improve outcome.1 A recent randomised controlled trial identified improvements in teamwork scores and markers of care after structured participation into clinical drills for obstetric emergencies, but further teamwork training based on a CRM model was not shown to confer any additional benefit.4 Moreover, it has been demonstrated in other healthcare settings and other high-risk industries the only definite beneficial outcome from CRM team training was a positive reaction from trainees. Even this reaction could be negative when training was out-of-context.5 Indeed, CRM training may even have a negative impact on teamwork: suboptimal team performance in 25% of cases, lack of leadership and subsequent communication clutter, and worse task execution behaviours.5
Teamwork training that is independent of task and context may therefore have limited benefit. Obstetric emergencies, in particular, may require the development of specific training and evaluation tools, rather than whole-scale adoption of potentially inappropriate models from aviation or other non-obstetric healthcare activities. There are a growing number of reports of training and safety interventions that have improved clinical and organisational outcome (Table 1). In this commentary, we will review the available evidence in an attempt to identify the active components of effective teamwork training in obstetrics.
Table 1. Emerging reports of improved outcomes with obstetric team training
|Southmead Hospital, Bristol, UK9,11,12||Infrastructural changes (protocols, props to help adherence to guidelines, practical solutions)|
Regular in-house clinical drills for all staff
|51% reduction in 5-minute Apgar <7|
50% reduction in Hypoxic Ischaemic Encephalopathy
75% reduction in Erb’s palsy after shoulder dystocia
40% reduction in median decision-delivery interval for cord prolapse
|BIDMC, Boston, USA6||Teamwork course for all staff|
Debriefings, improved handover
Selected clinical drills
|23% reduction in adverse obstetric events|
62% reduction in malpractice claims
Labour staff has more positive attitudes to safety than the rest of the hospital
|Liverpool Women’s Hospital, UK7||Integrated risk management|
Regular team briefings
|11% reduction in adverse events with identified suboptimal care|
50% reduction in 5-minute Apgar <4
50% reduction in cord pH <7
86% reduction in incidence of Erb’s palsy
|New Cross Hospital, Wolverhampton, UK10||‘In-house’ drills for all staff following the Southmead model||50% reduction in 5-minute Apgar <7|
|Copenhagen Denmark (Soerensen JL, MSc Thesis)||Clinical drills|
Eclampsia and haemorrhage boxes
|45% reduction in midwifery sick leave|
Institution-level incentives to training and safety culture
Several units have demonstrated improved organisational and patient outcomes after training (Table 1). A common characteristic of these units is a financial incentive to training, for example, lower medical malpractice insurance premiums are offered to clinicians and units with regular training: in the USA (Harvard-affiliated obstetricians) and the UK via national clinical negligence schemes.6,7 Local training may enhance the internal response to external incentives, as staff may be more likely to report a sustainable positive attitude towards management, safety climate and stress, when training ‘in-house’.8
There may be multiple barriers, such as cost, time away from work and staff attitude, to successful team training. These barriers may be more easily overcome by implementing ‘in-house’ drills, particularly, when such drills are part of a safety agenda that includes other essential elements: mandates from leadership, availability of resources and access to data.1
Relevant, ‘in-house’ training
All of the units that have reported improvements have implemented training programmes within their own unit and have trained almost 100% of their staff. It may be difficult to demonstrate improvements in outcome if it is only possible for a few members of staff to be trained at expensive external courses. ‘In-house’ simulation training is a less expensive option (S. Reading, pers. comm.).9
Assessment of safety and communication has been shown to be significantly improved when training is conducted in local hospitals using patient-actors compared to training at a simulation centre with computerised patient mannequins.10
At Southmead Hospital, Bristol, the maternity safety programme includes a one-day ‘in-house’ multi-professional training course that is held every 2 months to accommodate all midwifery staff, including managerial, community-based and part-time midwives, as well as all obstetric and anaesthetic medical staff. Annual attendance is mandatory and is recorded on a risk management database. All staff are allocated non-clinical time to attend training. The direct costs for the course are low and are covered by the departmental budget.9 The course uses principles and materials derived from the SaFE study and a combination of high-fidelity mannequins and low-cost props. The introduction of training has been associated with significant improvement in clinical outcomes.9,11,12
However, local training per se is not a panacea. It can be difficult to accommodate ‘in house’ training in busy clinical areas and in one UK maternity unit, the introduction of regular training was associated with an increased rate of perinatal asphyxia and serious neonatal injury, including brachial plexus injury.13 This suggests that not all training is equal and other features of the training should be closely examined.
Non-threatening assessment and training for the entire workforce
Methods that require learners to monitor and assess themselves, for example, briefings, debriefings and ‘dynamic’ feedback in between or after drills, the removal of authority gradients or the threat of testing and the promotion of a team ethos, all may lead to improved staff participation9 and performance.14
Obstetric units that achieved full participation in drills tended to be associated with improvement in perinatal outcomes.6,7,9 Poor performers might be less inclined to attend such drills or more likely to drop out, but when they are encouraged to attend the training regularly, clinical improvements can be achieved.8,9 The solution is to facilitate threat-free regular participation and to mandate and confirm regular annual attendance via appraisal schemes and central training databases.9
Self-directed infrastructural changes: local solutions to national problems
Training ‘on-site’ provides the opportunity for departments to use their corporate intelligence, where teams identify local safety problems that can be subsequently addressed with specific local solutions. Examples of safety innovations that have been introduced in units with ‘in-house’ training include: structured documentation proformas, electronic fetal monitoring stickers and eclampsia boxes,9 streamlined management protocols (J. L. Soerensen, pers. comm.), guidelines for specific emergencies and regular patient handover.6
Realistic training tools: high fidelity rather than high-tech
Multi-professional teams that are taught how to manage obstetric emergencies using simulation are more likely to demonstrate sustained improvements in their confidence, knowledge and clinical management of emergency situations compared to teams taught with a didactic lecture format.15 However, when designing obstetric training interventions, psychological and environmental fidelity may be more important than the technology used. Obstetric emergencies are unique in that there is significant ‘audience participation’. Effective communication with women and their families during emergencies is essential. Using a patient-actor, or integrating a patient-actor with a mannequin, is effective and inexpensive. The use of a patient-actor can increase the realism of the situation and improve communication between healthcare professionals and patients.10
High-fidelity technologically advanced trainers offer advantages for training individuals in highly technical skills.16 Training on a high-fidelity mannequin is associated with a significantly higher chance of successfully managing a simulated shoulder dystocia compared to training with low-fidelity models.17
Multi-professional teams: clinical and teamwork training
Obstetric emergencies require well-functioning teams that train regularly. However, a large UK survey of labour units demonstrated that only 51% of units run multi-professional drills. One of the reasons cited was that historically training programmes for midwives and doctors have always been separate.18
As identified by several confidential enquiries,2,3,19 there is a clear need for improved teamwork in the labour and delivery settings. However, multi-professional ‘in-house’ clinical training alone might improve team working, without the need for non-clinical teamwork theories as team members bond and train together. To the contrary, isolated teamwork interventions have not been shown to lead to improvements in outcome. A recent cluster randomised controlled trial1 studied the impact of standardised CRM (‘MedTeams’) teamwork training on 11 measures of maternal and neonatal outcome in seven American maternity units. More than thirteen hundred healthcare professionals were trained, but none of the clinical outcomes measured were significantly altered after the introduction of the team training intervention. There was also no significant change in 10 of the 11 process measures used to evaluate quality of care. However, when a unit that had been originally randomised to the teamwork (CRM) training intervention subsequently combined it with clinical training among other safety interventions, there was an associated improvement in outcome.6
The SaFE study demonstrated a significant improvement in clinical performance and team behaviour during simulation, after clinical training was given to multi-professional teams. However, there was no significant difference in knowledge, clinical performance or team behaviour between learners who had received additional teamwork training and those who were randomised to clinical training alone. The patient-actor perception of care was also not influenced by the addition of specific team work training. It appears that simply working in teams during clinical training can improve team working.4,10,16
It may be that CRM principles can be effective in obstetrics, but perhaps relevant teamwork interventions need to be refined and made directly applicable. Content analysis of the SaFE study simulated emergencies, demonstrated that additional teamwork training resulted in an increase in directed and addressed messages (as opposed to commands called out ‘in the air’), when compared with clinical training alone.8 However, this was not associated with improved simulated clinical performance. Perhaps, CRM training needs to be more context-specific before it can translate into better outcomes. Further work is required to determine the components of effective obstetric communication and to inform the design of effective nontechnical team training interventions as well as practical assessment tools. Once obstetric team training interventions have been refined and piloted, a large multicentre prospective study is required to evaluate whether improved team performance can translate to improved outcome for mothers and their babies.
Regular multi-professional ‘in-house’ drills are an effective method of training teams to manage obstetric emergencies. Such training may lead to sustainable improvement in learning and patient outcome, particularly, when it is part of a safety agenda that includes quality improvements similar to those described in the Institute for Health Improvement ‘Idealised Design for Perinatal Care’: effective communication among the mother, family and the care team; high-functioning multi-professional teams; reliable protocols; appropriate infrastructure that underlies the system of care.20 The application of CRM methodology has not been associated yet with definitive improvements in simulation performance or real-life outcomes.
The common features of all these units that have so far demonstrated improved outcomes are: institution-level incentives to train; high participation rate with regular, multi-professional ‘in house’ training; teamwork training integrated with clinical training and the use of high fidelity simulation models.
Disclosure of interests
Mr Draycott is a consultant to Limbs and Things Ltd, manufacturers of the PROMPT Birthing Simulator. None of the other authors own stock or hold stock options, in any obstetric emergency training company. Mr Draycott, Mrs Winter and Dr Crofts are members of the steering committee of PROMPT, a UK-based charity running training courses. They have no financial interest from this association. Dr Weiner is holder of the US License for PROMPT and also receives salary support from the PHS (R01 HL049041-13) and CDC (DP00187-3).
Contribution to authorship
D Siassakos conceived idea, authored manuscript. J Crofts co-authored and edited manuscript. C Winter co-authored manuscript and approved final version. C Weiner co-authored and edited manuscript. T Draycott conceived idea, co-authored and edited manuscript.
Details of ethics approval
The SaFE study––‘Simulation and Fire Drill Evaluation’ was funded by the Department of Health Patient Safety Programme. The sponsors have not been involved in the writing of this manuscript or the decision to submit for publication.
We are grateful to everyone involved in the SaFE study and the PROMPT Foundation.