Emergency Delivery Simulations: How to Develop Effective

TeamworkMichele R. Lauria MD, MS

Associate Professor OB/GYN

Medical Director NNEPQIN

Emergency Deliveries:Creating Excellence Out of Chaos

Objectives

• How process mapping improves clinical care• Establish the rate limiting steps in the

processes in emergency cesarean deliveries• Identify underutilized local resources that

could improve patient care• Describe how to initiate and learn from

simulation experiences• Develop tools to review and learn from

emergency cesarean deliveries and simulation experiences

Patient Safety & Simulation

Ideas from Jeffrey B. Cooper, PhD

Harvard medical School

Director, Center for Medical Simulation

Medical Errors

• Eighth leading cause of death USA

• Annual cost $29 billion

• Systems problems– Just like other industries– Columbia disaster

• Culture: show it is not safe

– Don’t’ recognize problems until the disaster

Quality

• What the medical errors experts say:– No one should be hurt by care process– Can’t have quality unless safety is first

• Model: High reliability organizational culture– High risk fields– Minimal accidents– Ie: Airlines, explosives, aircraft carrier

• Can we expand errors to include failure to follow recognized guidelines?– Errors folks say no….– Errors are rare events, quality issues are common

What is an Accident

• The Normal Accident• Unpredictable• Highly Complex• Highly Coupled/Interactive• More than one unexpected error

– Safety systems bypassed– Safety systems create error through chaos

• Poor Communication• Knowledge Deficit

Simulation

• Improve knowledge base– Management of rare events

• Tracheostomy traning in anesthesia– Early training of common problems

• Shoulder dystocia drills– Realistic & expensive

• Boston site $900/MD/day– Ie airlines, aerospace

• Team Training– ? How realistic… need elements– Fun is key– Sports teams

• Process mapping• Microsystems testing

Microsystem problems

• System weaknesses: procedures insensitive to how things really happen

• Latent failures: problems lurking throughout the care process

• Lack of teamwork: – Poor communication– Focus on hierarchy instead of expertise

• Failure to appreciate the limits of human performance• Cultures that blame people instead of system

– Don't learn about their problems– For fear of exposure, don't discuss problems

A Lesson from Anesthesia

• 1950-70's 1+mortalities/10,000 GET

• 1970's first studies of medical error and human factors

• 1980's malpractice crisis escalates– Media coverage of deaths and brain damage

• same thing is happening in OB

– Malpractice premiums increase

Anesthesia Solution

• President of the ASA made patient safety the primary theme and goal– Ensure no one is hurt– Free safety newsletter to everyone– Funded many safety projects and research– Partnered with industry

• Pulse oximetry• End tidal C02

• Standards for minimal monitoring– Simple and easy to accept– Start small, build incrementally.

• Studied closed claims• Simulation and crisis management

Anesthesia Today

• Risk GET in healthy individuals 1/100,00

• Premiums decreased – 1987 $35,000– 2001 $9,000

• Involve patients and families

• Disclose error

Elements of an HRO

• Safety #1 priority– Safety trumps production always

• Pre-occupation with failure• Commitment to resilience• Practice is routine• Deference to expertise, not hierarchy• Sensitivity to day to day operations

• Reliance on team work

Microsystem Lessons

• Standardization has benefits– OB is further than most fields in medicine

• Excessive procedure-alization can be counterproductive– Flexibility to meet individual patient needs

• Teams and microsystems are critical– Real teams train– Performance degrades when training stops– No one can tell me frequency of training

• Q 18 mos for skills

Creating Team Work

M&M Conferences/Debriefings

• Multidisciplinary– All staffing levels

• Open discussion of error– Or less than ideal perofrmance– “Near Misses”

• Supportive environment• No individual blame• Method of closing the loop

Near Miss Box

• Box to report events– What almost happened– What prevented it from happening– System fix

• Reward ideas and ingenuity– Unit Newsletter

Simulation: Two Processes

• NNEPQIN identifies ED critical area– Feb 9 process mapping– March Simulation drills, document refinement

• DHMC with VOX– Collaborative team training

• 8 participating hospitals

– Create the perfect video– Started 10/03

Eight Drills Completed Using Simulator

Steps:1. Instructor Creates a Scenario2. Pre- Meeting to Discuss Areas for

improvement from last drill3. Run the Drill, Video Taping all

ActionRequired Process Mapping

Drills Continued

4. Debrief Immediately After Drill– Replay video tape to Team– Discuss what we learned i.e.

• Went Well• Went Poorly• What to practice• Barriers

– Set Goals for next Drill

Everyone Participates

Creating Team Work

• Defined roles– Everyone understands other person’s role

• Speak Back

• Questioning

• Thinking the problem out loud

• Flat communication structure

Challenges

STAFFING FACTORS: • Difficult to assemble the same team on a routine basis• Team members roles and responsibilities were confusing

ENVIRONMENT/TECHNICAL: • Unable to have bio-med tech support after 3 pm • Problems with the STAT c-section paging system

BEHAVIOR FACTORS: • Letting go of what has been done in the past

PATIENT FACTORS: • Identifying the maternal/fetal factors that result in urgent or

STAT c-sections

Countermeasures

• Invited staff who were dissatisfied with the present process

• Held drills same time and day of the week• Viewed videotaped drill, which brought

realization to team members that team performance was not optimal

• Collaborated with key person experienced in teaching Team Performance

• Set time line for project

Lessons Learned

• Pagers frequently didn’t work– “Painted” Stat Pagers– Removed “forwarding” capabilities– Established Daily Testing Stat Paging System

• Reduced number of folks doing transport• Disconnecting IV’s• Reassigned MD tasks

– Critical communicators at scrub sink– Ask permission to leave room

• OR Grease Board: Meds, Allergies, Fetuses, Mec, GA, Indication

Principles for Drills

• Fun

• Create Tension– Asthmatic can’t be intubated, spinal not

working, heart rate going down

• Low Tech

• Dummy Chart

• Trainer

• Observers

Drill One

Sometime Months Later

What is our Real Purpose

• Create demonstration video

• Train new staff

• Test the system

• Practice for rare events

• Create a set of principles– Become ingrained– Permit flexible responses

The Normal Accident

• Highly Coupled Systems– Not a linear production– Transform a product

• Pregnant woman no longer is

• Complex Systems• Interactions unpredictable• Setting and Personnel Interact

Unpredictably• Never just one error or person

Swiss Cheese

NNEPQIN

• Ordinary people collaborating• Emergency Cesarean Section Tool Kit

– Simulation Planning Guide– Global Process Map– Detailed Process Map

• Solutions for common problems

– Simulation task evaluation form– Drill debriefing form– Emergency delivery debriefing form

• Patient/Family• Staff

NNEPQIN

• Roving Simulator• Common Trainer

– Share solutions, lessons learned

• Saturdays– After 2 weeks of having simulator locally

• Provide regional data analysis– QA protected– ? IRB approval

Materials Available @ NNEOB.org

Patient needs stat C/S

Decision made to do stat C/S

Notify Unit

Notify teams

Move patient to OR

Reevaluate in OR

Prepare for C/SAnesthesia

ScrubfoleyPrep

SuctionDelivery Baby

Pt potential need for stat

C/S

Consent for possible C/S

Notify teams of possibility

Prepare for possibility

Patient delivers

Take everyone off alert

Resuscitate baby

Communicate with family

Finish C/SCount

Change glovesAntibiotic prophylaxis

X-ray if no pre-op count done

If GET, is there a risk for pneumonia?

Debrief Unit

Debrief Patient & Family

Global Process Map