Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes

Problem Addressed

Please note that the training described in this innovation summary is specific to obstetric emergencies.However, teamwork and communication skills are also addressed in TeamSTEPPS. 

Although relatively uncommon, obstetric emergencies still affect thousands of individuals and can have devastating consequences for the baby, family, and providers, and cost millions of dollars in malpractice insurance claims. Effective communication and teamwork can improve outcomes during obstetric emergencies but clinical teams often are not prepared to react quickly and appropriately during these unpredictable events.

• Relatively rare, but still affecting thousands: Birth trauma occurs in approximately 7.4 out of every 1,000 live births in the United States. For example, shoulder dystocia (when the baby's shoulders cannot move past the mother's pelvis during delivery), which occurs in approximately 5 percent of births, can lead to birth trauma if not handled properly. Serious forms of potential maternal morbidity are reported in an average of less than 1 percent of births; for example, maternal cerebrovascular accident occurs in less than 0.1 percent of births, while eclampsia and postnatal hemorrhage occur in approximately 0.1 percent and 2 percent of deliveries, respectively. However, with roughly 4 million deliveries annually, thousands of women and their babies still end up being affected by these events.
• Devastating consequences: Obstetric emergencies—particularly those resulting in birth trauma—are emotionally and financially devastating to families and result in long-term costs to providers and society, including rapidly rising litigation expenses (leading some physicians to stop delivering babies altogether) and an escalation in use of costly cesarean sections and operative vaginal deliveries to minimize the potential for birth trauma in high-risk situations.
• Largely unrealized benefits of practicing team responses: The most common adverse events that occur during birth are largely preventable. For example, proper maneuvering can prevent injury in shoulder dystocia cases. Yet, up to 25 percent of deliveries in these cases result in an injury to the nerves that control movement and sensation in the arm, with permanent damage occurring in up to 10 percent of babies. Although simulation training can provide opportunities to hone the team's response during actual emergencies and prevent adverse events, very few hospitals have such programs in the United States.

Description of the Innovative Activity

Multidisciplinary teams simulate the most common obstetrical emergency situations and practice an optimal response. Clinicians then use what they learn during real emergency situations. The PROMPT program includes didactic sessions on these common situations, teaching and practicing structured communication techniques to facilitate information sharing during actual emergencies, and simulations in which clinicians perform requisite skills and receive real-time feedback on their performance. Key elements of the PROMPT program as implemented at the University of Kansas included the following:

• Program logistics: All personnel working in the labor and delivery suite, including obstetrician/gynecologists, pediatricians, anesthesiologists, nurses, clerical staff, and others, attended a mandatory annual 2-day training through the PROMPT system. You can never know who will be available in an emergency. The University of Kansas Hospital offered the course five times per year, with roughly 50 individuals attending each session. Sessions were led by physician instructors, masters-level nurses and senior labor suite nursing staff who had completed PROMPT training previously. Training was required annually because benefits have been demonstrated to wane after 12 months. 
• Preparation for rehearsal: The PROMPT sessions emphasized two key areas where care processes need to be improved—responses to common emergency scenarios and structured communication to facilitate information sharing during an actual emergency.
  • Optimal response to emergency scenarios: Didactic sessions outlined the care steps clinicians should take to optimize outcomes when faced with an obstetric emergency. Sessions focused on the appropriate response to a variety of potential emergency situations that may occur, including maternal hemorrhage, maternal cardiac or pulmonary arrest, sepsis, anesthetic emergencies, eclampsia (convulsions), hypertensive crisis (a severe increase in the mother's blood pressure that can lead to a stroke), umbilical cord prolapse (in which the cord passes through the cervix ahead of the baby), shoulder dystocia, breach delivery, forceps delivery, multiple gestation, and interpretation of fetal heart rate tracings. Sessions included didactic modules held during the morning, structured as a series of short (15-minute) lectures, followed by 15 minutes of audience participation allowing for questions, discussion of current practices, and suggestions for process change.
  • Structured communication techniques: Participants learned structured communication, teamwork and situational awareness/leadership techniques as part of each didactic module, including watching a videotape illustrating poor and optimal communication. The sessions include an organized method for communicating key information about the patient's condition and instructions regarding equipment, testing, and staff. This initial communication was followed by the participant's repeating the information to confirm receipt and understanding. Participants practice these structured communication techniques in the simulations (see below), and were encouraged to use them in daily care situations. Participants also received and learned to use forms to document communication.
• Simulation exercises with real-time performance feedback: After the didactic modules, attendees participated in a half day of simulations that allowed them to practice the care steps discussed earlier in the day. Five multiprofessional teams with 10 participants each rotated through five stations, each covering a different emergency scenario. In most cases, midwives, nurses, and medical students acted as “patient and/or and family” reacting to the care they were receiving. Sometimes, participants use a high fidelity pelvis and a mannequin for teaching/demonstration purposes. For delivery manuvers, high fidelity manniquins are associated with enhanced learning. During the simulation, the trainer offers real-time feedback regarding clinical and communication processes. For example, the trainer may stop the team to remind them of an omitted step or may change the simulation to reflect the negative consequence of forgetting that step. At the end of the simulation, the participants are asked to assess their own performances.

Context of the Innovation

Results demonstrating the success of PROMPT in North America come from implementation at the University of Kansas Hospital. The University of Kansas Hospital, an academic institution with approximately 606 beds and 13 labor rooms, handles approximately 1,900 deliveries each year. Dr. Carl Weiner, Professor and Chair of the Department of Obstetrics and Gynecology and now Director of PROMPT for North America, learned about PROMPT while attending a conference in New Zealand. Impressed by the randomized trial data supporting the link between the training and better birth outcomes, Dr. Weiner sought and received approval in 2006 for the University of Kansas Hospital to serve as the PROMPT representative in North America. PROMPT, developed in the United Kingdom's National Health Service by a team led by Dr. Tim Dracott, is the only simulation model in obstetrics that has been shown via prospective clinical trials to improve patient outcomes.

Results

At the University of Kansas, the program reduced rates of primary cesarean delivery, transient brachial plexus injury (no permanent injury for > five years ), halved the incidence of hypoxic ischemic encephalopathy at term, shortened decision-to-delivery times, the need for blood transfusions, and the incidence of acidemic newborns. Anecdotal reports suggest that the program improved management of emergency situations, and malpractice premiums have fallen since program implementation. Studies from the United Kingdom found that the program improved outcomes, task completion, medication administration, caregiver response times, and caregiver knowledge.  There have been dramatic decreases in medical negligence claims and payments in both the UK and in the State of Victoria, Austrailia.

Results From University of Kansas Hospital¹¹

• Improvement in outcomes: The impact of PROMPT on patient outcomes was both progressive and sustained. After 7 years of annual training of all personnel who work on the labor and delivery unit of the University of Kansas Hospital, the number of cesarean deliveries decreased to a nadir of 21.8 percent (primary rate below ten percent), there had been no brachial plexus injuries in 3 years despite an unchanged rate of shoulder dystocia, the rate of hypoxic ischemic encephalopathy in term infants was more than halved (less than 7 per 10,000 deliveries) and the annual proportion of umbilical artery pH of < 7.00 among term deliveries uncomplicated by major fetal malformation reduced. 
• Anecdotal reports of better management of emergency situations: Coincidentally, the hospital's labor and delivery unit faced three emergencies during the first week after the initial training: a postpartum hemorrhage, a baby with shoulder dystocia, and a breech delivery. Staff resolved all three emergencies successfully by using techniques practiced during simulations, achieving positive outcomes. All involved staff commented on how well prepared they felt to handle these cases as a result of the simulations. Anecdotal reports over the first 3 years of implementation suggest that clinician performance during emergency situations has improved since implementation of PROMPT. Surveys administered to nurses during the 6 years following initiation also indicated significant improvement in the nurses’ perception of their interactions with the physician staff.
• Savings on annual liability premiums: Since adopting PROMPT, the hospital's annual malpractice insurance premium fell significantly (actual cost savings not available).
• Costs avoided from decreased cesarean deliveries: University of Kansas reported substantial cost avoidance associated with a reduction in cesarean delivery direct costs for cesarean delivery, an estimated $4.4 million over 7 years.  

Results From the United Kingdom

• Better outcomes: A retrospective cohort observational study found that, after the introduction of PROMPT, the number of infants with Apgar scores less than or equal to 6 decreased from 86.6 to 44.6 per 10,000 births, and the number of infants with hypoxic-ischemic encephalopathy (central nervous system damage resulting from inadequate oxygen) decreased from 27.3 to 13.6 per 10,000 births.⁵ Another retrospective observational study found that the program led to a 70 percent reduction in brachial plexus injuries following shoulder dystocia and the virtual elimination of permanent injuries.⁶ An additional retrospective observational study found that 12 years after the introduction of training for all maternity staff, compliance with national standard fetal morbidity associated with should dystocia was very low and that there were no cases of permanent BPI in the last four years of follow-up, which included more than 17,000 vaginal births.¹⁰ 
• Improved task completion, medication administration, and response times for eclampsia patients: A randomized controlled trial (RCT) focused on the care of patients with eclampsia found that PROMPT training increased team communication and efficiency and with that the completion rates for basic tasks (100 percent completion rates in the training group, compared with 87 percent in the control group); led to quicker completion of these tasks (27 vs. 55 seconds); increased administration of appropriate medications (92 vs. 61 percent); and reduced median administration time for these medications (by 116 seconds).⁷
• Enhanced knowledge: A prospective RCT found that obstetrician and midwife knowledge about emergency management significantly increased after training, with scores on a 185-question multiple choice questionnaire increasing by an average of 20.6 points. Training and implementation improved retention of knowledge, and clinical skills. Training demonstrated benefit for up to 12 months and improved compliance with clinical standards and helped to reduce clinical errors.⁸

Results from Australia⁹

• Better outcomes: A RCT found significant reduction in percent of cases that had Apgar 1 scores<7, reducing from 9.1% before PROMPT to 8.3% during the training period. The study also found significant reduction of cord lactate values > 5.27mol/l before PROMPT, during the training period, and after the training period (25%, 24.7%, 23.4%). Finally, there was a significant reduction in the length of stay seen during training (mean [SD]: 2.79 [1.55] days) compared with pretraining (2.82 [1.55] days). 
• Increased safety attitude: As measured by Safety Attitude Questionnaire, this same RCT found a significant increase in teamwork, safety, and perception of management scores following staff PROMPT training.  
• Reduction in claims frequency: In Victoria, Australia, after introducing PROMPT hospitals saw a 53% overall reduction in obstetric claims frequency (p=0.008).

Planning and Development Process

Key elements of the planning and development process from the experience at the University of Kansas included the following:

• Obtaining approval from senior leadership: Dr. Weiner proposed the adoption of the evidence-based program, PROMPT, to senior hospital administrators, who reacted enthusiastically to the idea.
• Obtaining and “Americanizing” PROMPT materials: Since PROMPT had been developed and tested in the United Kingdom, Dr. Weiner needed to secure approval to license and distribute program materials in the United States. After doing so, he amended the materials for American audiences by adjusting language and ensuring that the clinician relationships and organizational processes described reflected the U.S. health care system.
• Selecting and training the trainers: Dr. Weiner identified staff to serve as trainers, selecting obvious choices for the role, including, for example, the director of nursing education and a perinatologist. He then administered the course to these individuals and held several rehearsals.
• Piloting and rolling out program: Dr. Weiner held a “trial run” of the program during an abbreviated, half-day session that included obstetricians, faculty, and nurses. After this trial, the labor and delivery department scheduled all involved individuals (approximately 200 people) for one of two 2-day courses, conducted several days apart.
• Adjusting schedule: Because training all individuals during the same week proved logistically difficult, the hospital scheduled sessions on a quarterly basis, with approximately 50 people attending each session.

Resources Used and Skills Needed

• Staffing: The PROMPT program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: PROMPT is distributed in the United States by PROMPT North America, which holds 2 day Train the Trainer courses throughout the year. The courses include the training of 4 foundational local instructors, all lectures and slides, copies of the PROMPT Participant and Trainer Manuals (Cambridge University Press) and an unrestricted local license. In 2020, the associated cost for the course was $15,000 one-time fee. The primary ongoing costs relate to the labor expenses needed to provide patient coverage while staff members attended the program. Mannequin simulators for shoulder dystocia can also be purchased from manufacturers, but the course can be run without these or any other specialized simulation equipment.

Tools and Resources

Hospitals can purchase PROMPT materials from or PROMPT North America.  More information is available at the PROMPT Web site: http://www.promptmaternity.org/.

Getting Started with This Innovation

• Obtain commitment from all parties: Senior management, clinicians, nurses, and other frontline staff must all believe in the value of process improvement. Although academic medical centers can require faculty to participate, community hospitals may find it more difficult to mandate that physicians do so. Identifying specific champions can help to encourage provider buy-in and participation. 
• Customize to site-specific characteristics: Adopters should customize the program to reflect the care and operational processes within their own institutions.

Sustaining This Innovation

• Repeat annually: Sessions should be repeated annually to refresh clinician skills in handing these relatively rare events. PROMPT studies have shown that the skills and learning persist for approximately 1 year, but then begin to wane if staff do not re-review their training materials. 
• Seek insurer support: Share data with insurers on program outcomes and request that they lower malpractice premiums for hospitals and providers that participate in the program. These premium reductions can serve as a strong incentive to participate.

References/Related Articles

Ghag K, Winter C, Bahl R, et al. A rapid cycle method for local adaptation of an obstetric emergencies training program. Int J Gynaecol Obstet 2018;141(3):393-398. [PubMed]

Draycott T. Not all training for obstetric emergencies is equal, or effective. BJOG 2017;124(4):651. [PubMed]

Crofts JF, Lenguerrand E, Bentham GL, el at. Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2016;123(1):111. [PubMed]

Weiner CP, Collins L, Bentley S, et al. Multi-professional training for obstetric emergencies in a US hospital over a 7-year interval: an observation study. J Perinatol 2016;36:19-24. [PubMed]

Crofts JF, Mukuli T, Murove bt, et al. Onsite training of doctors, midwives and nurses in obstetric emergencies, Zimbabwe. Bull World Health Organ 2015;93(5):347-351. 

Draycott TJ, Collins KJ, Crofts JF, et al. Myths and realities of training in obstetric emergencies. Best Pract Res Clin Obstet Gynaecol 2015;29(8):1067-76. [PubMed]

Shoushtarian M, Barnett M, McMahon F, Ferris J. Impact of introducing practical obstetric multi-professional training (PROMPT) into maternity units in Victoria, Australia. BJOG 2014;121(13):1710-8. [PubMed] 

Siassakos D, Fox R, Bristowe K, et al. What makes maternity teams effective and safe? Lessons from a series of research on teamwork, leadership and team training. Acta Obstet Gynecol Scand 2013;92(11):123943. 

Crofts JF, Fox R, Draycott TJ, et al. Retention of factual knowledge after practical training for intrapartum emergencies. Int J Gynaecol Obstet 2013;123(1):81-5. [PubMed]

Siassakos D, Bristowe K, Hambly H, et al. Team communication with patient actors: findings from a multisite simulation study. Simul Healthc 2011;6(3):143-9. [PubMed] 

Vierthaler M. Training Program Reborn at KU. August 13. 2008. Lawrence Journal World & News. Available at: http://www2.ljworld.com/news/2008/aug/13/training_program_reborn_ku.

The University of Kansas Hospital. The University of Kansas Hospital Offers Unique Training In Delivering Babies. August 5, 2008. Available at: http://www.kumed.com/newsroom/news/unique-training-in-delivering-babies

Crofts JF, Ellis D, Draycott TJ, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation centre, and teamwork training. BJOG 2007;114(12):1534-41. [PubMed]

Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006;113(2):177-82. [PubMed]
 

Footnotes

1.    Vierthaler M. Training Program Reborn at KU. August 13. 2008. Lawrence Journal World & News. Available at:http://www2.ljworld.com/news/2008/aug/13/training_program_reborn_ku/.
2.    Institute for Healthcare Improvement. Seton Family of Hospitals: Where the Birth Trauma Rate is Essentially Zero. IHI Annual Progress Report, 2008. Available at:http://www.ihi.org/knowledge/Pages/ImprovementStories/SetonBirthTraumaRateIsEssentiallyZero.aspx.
3.    Danel I, Berg C, Johnson CH. Magnitude of maternal morbidity during labor and delivery: United States, 1993-1997. Am J Public Health 2003;93(4):631-4. [PubMed]
4.    MacLennon A, Nelson KB, Hankins G, et al. Who will deliver our grandchildren: implications of cerebral palsy litigation. JAMA 2005;294(13):1688-90. [PubMed]
5.    Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006;113:177-82. [PubMed]
6.    Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008 Jul;112(1):14-20. [PubMed]
7.    Ellis D, Crofts JF, Hunt LP, et al. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol. 2008;111(3):723-31. [PubMed]
8.    Crofts JF, Ellis D, Draycott TJ, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation centre, and teamwork training. BJOG 2007;114:1534-41.[PubMed]
9.    Shoushtarian M, Barnett M, McMahon F, Ferris J. Impact of introducing practical obstetric multi-professional training (PROMPT) into maternity units in Victoria, Australia. BJOG 2014;121(13):1710-8. [PubMed] 
10.    Crofts JF, Lenguerrand E, Bentham GL, el at. Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2016;123(1):111. [PubMed]
11.    Weiner CP, Collins L, Bentley S, et al. Multi-professional training for obstetric emergencies in a US hospital over a 7-year interval: an observation study. J Perinatol 2016;36:19-24. [PubMed]
 

Original Publication

October 28, 2009

Date Verified by Innovator

November 11, 2020