Journal of Pediatric and Adolescent Gynecology, 2020
Conclusions: There is large variation in opioid prescribing patterns across PAG providers, and fe... more Conclusions: There is large variation in opioid prescribing patterns across PAG providers, and few PAG providers utilize ERAS opioid-sparing protocols. Our study suggests that avoidance of OPR in the postoperative recovery of minor and major vaginal surgery is reasonable. Although over half of practitioners prescribe OPR after minor and major laparoscopic surgeries, a sizable minority of individuals do not, suggesting another opportunity for possible OPR use minimization. The opioid epidemic is a significant public health threat, and judicious use of OPR is integral in combatting opioid misuse. Future prospective studies should focus on moving toward improvement in peri-operative care and pain medication prescribing patterns by implementing multi-modal opioid-sparing ERAS protocols that limit overall OPR use in this vulnerable patient population.
Background: Women are over 3 times more likely to die in childbirth in Peru compared to the Unite... more Background: Women are over 3 times more likely to die in childbirth in Peru compared to the United States. Peru has had considerable success in diminishing maternal mortality rate (MMR, defined as the annual number of female deaths per 100,000 live births); nonetheless, poor, rural populations remain underserved medically. This study is designed to compare the MMR in urban areas to the rural mountain town of Otuzco, Peru.
International Journal of Gynecology & Obstetrics, 2021
ObjectiveTo evaluate simulation‐based training (SBT) in low‐ and‐middle‐income countries (LMIC) a... more ObjectiveTo evaluate simulation‐based training (SBT) in low‐ and‐middle‐income countries (LMIC) and the long‐term retention of knowledge and self‐efficacy.MethodsWe conducted an SBT course on the management of postpartum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) in three government teaching hospitals in Guatemala. We evaluated changes in knowledge and self‐efficacy using a multiple‐choice questionnaire for 46 obstetrics/gynecology residents. A paired Student's t test was used to analyze changes at 1 week and 6 months after the SBT.ResultsThere was an increase in scores in clinical knowledge of MCA (p < 0. 001, 95% confidence interval [CI] 0.81–1.49) and SD (p < 0.001, 95% CI 0.41–1.02) 1 week after SBT, and a statistically insignificant increase in PPH scores (p = 0.617, 95% CI −0.96 to 0.60). This increase in scores was maintained after 6 months for MCA (p < 0.001, 95% CI 0.69–1.53), SD (p = 0.02 95% CI 0.07–0.85), and PPH (p = 0.04, 9...
To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nullip... more To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women. STUDY DESIGN: Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24 h, mode of delivery and maternal and fetal outcomes. RESULT: A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9 h, Po0.0001) and were more likely to deliver vaginally in o24 h (47% vs 64%, P ¼ 0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes. CONCLUSION: Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.
You're cruising comfortably at 35,000 feet when your plane experiences severe turbulence as the r... more You're cruising comfortably at 35,000 feet when your plane experiences severe turbulence as the result of a sudden squall. Your knuckles are white from clutching the armrest when the pilot comes on over the loudspeaker: "Well folks, we are going to have to make an emergency landing due to inclement weather. I've never actually done this before, but no worries.. .I've seen senior pilots do it." Unimaginable? Training that puts a pilot in the cockpit of an airliner without having practiced responses to common dangerous scenarios is perhaps unimaginable in the aviation industry, where cockpit simulator experience is a mandatory component of training. Indeed, pilots practice responses to many such challenges before they are put in a position in which any failure to act could compromise passenger safety. However, "see one, do one, teach one" has been considered standard operating procedure in medical education for dozens of years. Finally, this model is beginning to change, transitioning to "see one, practice many, do one." Health care is one of the last high-stakes industries to adopt simulation as an andragogical tool to improve patient safety.
When implementing a simulation program, the initial question is WHY? Why are you embarking on a s... more When implementing a simulation program, the initial question is WHY? Why are you embarking on a simulation program? Is it for residency training, team performance improvement, or improvement of your unit workflow with identification of latent system errors? After the WHY is clearly defined, the subsequent questions, who, what, and where, are easily answered. WHO do you need to accomplish the predetermined goal, and how do you best engage them. The WHO includes identifying your learners, team members, and the stakeholders. All must be committed to ensure the program will be a success. Strategies to engage WHO vary and options are discussed. The WHAT encompasses the curriculum and equipment including creating a safe zone where learners can practice new and difficult skills without judgment. WHERE defines the site of the simulation whether it is a simulation lab, in situ on labor and delivery, or a classroom, each offering pros and cons. Strategies for a careful and thoughtful introduction of a simulation program are presented. Successful planning will ensure your effort will become an integral component of a comprehensive patient safety program.
Comprehensive Healthcare Simulation: Obstetrics and Gynecology, 2019
When implementing a simulation program, the initial question is WHY? Why are you embarking on a s... more When implementing a simulation program, the initial question is WHY? Why are you embarking on a simulation program? Is it for residency training, team performance improvement, or improvement of your unit workflow with identification of latent system errors? After the WHY is clearly defined, the subsequent questions, who, what, and where, are easily answered. WHO do you need to accomplish the predetermined goal, and how do you best engage them. The WHO includes identifying your learners, team members, and the stakeholders. All must be committed to ensure the program will be a success. Strategies to engage WHO vary and options are discussed. The WHAT encompasses the curriculum and equipment including creating a safe zone where learners can practice new and difficult skills without judgment. WHERE defines the site of the simulation whether it is a simulation lab, in situ on labor and delivery, or a classroom, each offering pros and cons. Strategies for a careful and thoughtful introduction of a simulation program are presented. Successful planning will ensure your effort will become an integral component of a comprehensive patient safety program.
Cesarean delivery is the most common surgery performed in the United States, accounting for appro... more Cesarean delivery is the most common surgery performed in the United States, accounting for approximately 32% of all births. Emergency Cesarean deliveries are performed in the event of critical maternal or fetal distress and require effective collaboration and coordination of care by a multidisciplinary team with a high level of technical expertise. It is not well understood how the physical environment of the operating room (OR) impacts performance and how specialties work together in the space.ObjectiveThis study aimed to begin to address this gap using validated techniques in human factors to perform a participatory user-centered analysis of physical space during emergency Cesarean.MethodsThis study employed a mixed-methods design. Focus group interviews and surveys were administered to a convenience sample (n = 34) of multidisciplinary obstetric teams. Data collected from focus group interviews were used to perform a task and equipment analysis. Survey data were coded and mapped...
The Joint Commission Journal on Quality and Patient Safety, 2020
OBJECTIVE A pilot study was conducted in a tertiary referral center to assess whether wearing cap... more OBJECTIVE A pilot study was conducted in a tertiary referral center to assess whether wearing caps labeled with providers' names and roles has an impact on communication in the operating room (OR). METHODS Two obstetricians observed surgeries for name uses and missed communications. Following each case, all providers were given a short survey that queried their attitude about the use of labeled surgical caps, their ability to know the names and roles of other providers during a case, and the impact of scrub attire on identifying others. They were also asked to rate the ease of communication and their ability to recall name and roles of the personnel specific to the case. Patients were asked how they perceived the use of labeled caps by providers. RESULTS Twenty scheduled cesarean deliveries were randomized to either labeled (10) or nonlabeled (10) surgical caps. A total of 129 providers participated in the study, with 117 providing responses to the survey. Providers reported knowing the names and roles of colleagues more often with labeled caps vs. nonlabeled caps (names: 77.8% vs. 55.0%, 95% confidence interval [CI] = 64.4%-88.0% vs. 41.6%-67.9%, p = 0.011; roles: 92.5% vs. 78.3%, 95% CI = 81.8%-98.0% vs. 65.8%-88.0%, p = 0.036). Name uses increased (43 vs. 34, p = 0.208), and missed communications decreased (16 vs. 20, p = 0.614) when labeled caps were worn. Providers and patients had an overwhelmingly positive response to labeled caps. CONCLUSION This pilot study demonstrated that wearing labeled caps in the OR led to more frequent name uses and less frequent missed communications. Providers and patients embraced the concept of labeled caps and perceived wearing labeled caps as improving communication in the OR.
American Journal of Obstetrics and Gynecology, 2011
To determine whether adhesions at first repeat cesarean delivery predicts skin incision to neonat... more To determine whether adhesions at first repeat cesarean delivery predicts skin incision to neonatal delivery times. STUDY DESIGN: This is a secondary analysis of a prospective cohort study of women who underwent a first repeat CD. Immediately following a first repeat cesarean delivery, surgeons scored the severity and location of adhesions. Surgeons were asked to categorize adhesions as none, filmy, or dense, and to identify their presence among specified locations including uterus, fascia, omentum, bowel, and "other". We then summed weighted scores for each patient based on the presence and type of adhesions at each site: 0 (no adhesions),
Simulation in healthcare : journal of the Society for Simulation in Healthcare, 2008
The leading causes of pregnancy-related death are embolism (20%), hemorrhage (17%), and pregnancy... more The leading causes of pregnancy-related death are embolism (20%), hemorrhage (17%), and pregnancy-induced hypertension (16%).The Obstetric and Mechanical Engineering Departments at Stanford University worked together to create inexpensive devices that were used in high fidelity simulations to replicate 2 of the leading causes of maternal mortality: hemorrhage and eclampsia (seizure). The mechanisms were designed to behave as similarly as possible to a human patient. The engineering team designed the eclampsia mechanism to jostle the mannequin's head at a frequency and randomness that matched those observed in human generalized seizures. The hemorrhage mechanism was designed to give visual and tactile cues similar to the actual physiology of a pregnant uterus. Both devices were remote controlled. The hemorrhage mechanism was used in a scenario of an amniotic fluid embolism with severe postpartum hemorrhage. The final flow rate was adjustable between 525 and 600 mL/min. The traine...
Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 2014
Objectives The management of the critically ill obstetric patient is an essential component in th... more Objectives The management of the critically ill obstetric patient is an essential component in the training of an emergency medicine (EM) resident physician. Due to advances in the quality of perinatal care, many obstetric emergencies such as eclampsia and postpartum hemorrhage, are infrequently encountered in the emergency department. Other conditions such as peripartum cardiac arrest requiring perimortem cesarean section, are such rare occurrences that most residents will never experience such a case during their training. Nonetheless, EM residents must acquire the knowledge and skills to appropriately diagnose and manage a broad spectrum of obstetric emergencies. In recent years, the potential role for simulation in obstetrics training has become increasingly apparent. Simulation has been shown to improve the confidence and performance of Obstetrics and Gynecology residents.1-2 However, the use of simulation-based obstetrics training programs in EM residencies has not been described. We have developed and successfully implemented a multi-modal simulation-based curriculum to educate EM residents in the management of uncommon yet critical obstetric emergencies. Description An experienced group of educators from the specialties of Emergency Medicine and Obstetrics and Gynecology gathered to design and implement a simulation-based obstetrics course for EM resident trainees. The 2013 Model of the Clinical Practice of Emergency Medicine was used to determine the educational goals for the curriculum, with the focus on “critical” obstetric conditions that are encountered during the peripartum period.3 Three different simulation modalities were employed to provide instruction on the selected obstetric emergencies. High-fidelity manikin scenarios, paired with structured debriefing, were used to simulate cases of peripartum cardiac arrest and postpartum hemorrhage. Management strategies for eclampsia and chest pain in pregnancy were reviewed in a mock oral board examination format. Skills stations with task trainers were used to discuss the approach to uterine atony, vaginal delivery with a nuchal cord, shoulder dystocia, and breech delivery. Nine PGY-2 EM residents participated in this course. Anonymous pre- and post-course surveys were distributed assessing the participants’ confidence levels before and after completing the course as well as their satisfaction with the course. Conclusion Overall, residents felt more confident in managing obstetric emergencies after completing this simulation-based course. They reported statistically significant post-course improvements in confidence levels in managing postpartum hemorrhage (P=0.023), myocardial infarction in pregnancy (P<0.001), and peripartum cardiac arrest (P<0.001), as well as the indications for performing a perimortem cesarean section (P<0.001). Participants also demonstrated statistically significant improvements in confidence in recognizing and managing shoulder dystocia (P=0.005) and delivering a fetus in breech presentation (P<0.001). Feedback from residents was overwhelmingly positive. This course has been taught to one class of residents at a single residency program. At this time, it is unknown if participating in the course improves performance. In the future, this course will become a required component of the residency’s educational curriculum and may even be implemented at other simulation centers. It will be important to formally evaluate the impact of the course on improving resident clinical and technical skills. This multi-modal simulation-based curriculum provides a comprehensive approach to training EM residents to manage critically ill obstetric patients in the emergency department. References 1. Hirakoa M, Kamikawa G, McCartin R, Kaneshiro B. A pilot-structured resident orientation curriculum improves the confidence of incoming first-year obstetrics and gynecology residents. Hawaii J Med Pub Health 2003;72:387-390. 2. Daniels K, Arafeh J, Clark A, Waller S, Druzin M, Chueh J. Prospective randomized trail of simulation versus didactic teaching for obstetrical emergencies. Simul Healthc 2010;5:40-45. 3. Counselman FL, Borenstein MA, Chisholm CD, Epter ML, Khandelwal S, Kraus CK, Luber SD, Marco CA, Promes SB, Schmitz G, Keehbauch JN. The 2013 model of the clinical practice of emergency medicine. Acad Emerg Med 2014;21:574-598. Disclosures None
Communication and teamwork deficiencies have been identified as major contributors to poor clinic... more Communication and teamwork deficiencies have been identified as major contributors to poor clinical outcomes in the labor and delivery unit. In response to these findings, multidisciplinary simulation-based team training techniques have developed to focus specifically on skills training for teams. The evidence demonstrates that multidisciplinary simulation-based team training minimizes poor outcomes by perfecting the elusive teamwork skills that cannot be taught in a didactic setting. Multidisciplinary simulation-based team training is also being used to detect latent system errors in existing or new units, to rehearse complicated procedures (surgical dress rehearsal), and to identify knowledge gaps of labor and delivery teams. Multidisciplinary simulation-based team training should be an integral component of ongoing quality-improvement efforts to ultimately produce teams of experts that perform proficiently.
Journal of Pediatric and Adolescent Gynecology, 2020
Conclusions: There is large variation in opioid prescribing patterns across PAG providers, and fe... more Conclusions: There is large variation in opioid prescribing patterns across PAG providers, and few PAG providers utilize ERAS opioid-sparing protocols. Our study suggests that avoidance of OPR in the postoperative recovery of minor and major vaginal surgery is reasonable. Although over half of practitioners prescribe OPR after minor and major laparoscopic surgeries, a sizable minority of individuals do not, suggesting another opportunity for possible OPR use minimization. The opioid epidemic is a significant public health threat, and judicious use of OPR is integral in combatting opioid misuse. Future prospective studies should focus on moving toward improvement in peri-operative care and pain medication prescribing patterns by implementing multi-modal opioid-sparing ERAS protocols that limit overall OPR use in this vulnerable patient population.
Background: Women are over 3 times more likely to die in childbirth in Peru compared to the Unite... more Background: Women are over 3 times more likely to die in childbirth in Peru compared to the United States. Peru has had considerable success in diminishing maternal mortality rate (MMR, defined as the annual number of female deaths per 100,000 live births); nonetheless, poor, rural populations remain underserved medically. This study is designed to compare the MMR in urban areas to the rural mountain town of Otuzco, Peru.
International Journal of Gynecology & Obstetrics, 2021
ObjectiveTo evaluate simulation‐based training (SBT) in low‐ and‐middle‐income countries (LMIC) a... more ObjectiveTo evaluate simulation‐based training (SBT) in low‐ and‐middle‐income countries (LMIC) and the long‐term retention of knowledge and self‐efficacy.MethodsWe conducted an SBT course on the management of postpartum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) in three government teaching hospitals in Guatemala. We evaluated changes in knowledge and self‐efficacy using a multiple‐choice questionnaire for 46 obstetrics/gynecology residents. A paired Student's t test was used to analyze changes at 1 week and 6 months after the SBT.ResultsThere was an increase in scores in clinical knowledge of MCA (p < 0. 001, 95% confidence interval [CI] 0.81–1.49) and SD (p < 0.001, 95% CI 0.41–1.02) 1 week after SBT, and a statistically insignificant increase in PPH scores (p = 0.617, 95% CI −0.96 to 0.60). This increase in scores was maintained after 6 months for MCA (p < 0.001, 95% CI 0.69–1.53), SD (p = 0.02 95% CI 0.07–0.85), and PPH (p = 0.04, 9...
To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nullip... more To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women. STUDY DESIGN: Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24 h, mode of delivery and maternal and fetal outcomes. RESULT: A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9 h, Po0.0001) and were more likely to deliver vaginally in o24 h (47% vs 64%, P ¼ 0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes. CONCLUSION: Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.
You're cruising comfortably at 35,000 feet when your plane experiences severe turbulence as the r... more You're cruising comfortably at 35,000 feet when your plane experiences severe turbulence as the result of a sudden squall. Your knuckles are white from clutching the armrest when the pilot comes on over the loudspeaker: "Well folks, we are going to have to make an emergency landing due to inclement weather. I've never actually done this before, but no worries.. .I've seen senior pilots do it." Unimaginable? Training that puts a pilot in the cockpit of an airliner without having practiced responses to common dangerous scenarios is perhaps unimaginable in the aviation industry, where cockpit simulator experience is a mandatory component of training. Indeed, pilots practice responses to many such challenges before they are put in a position in which any failure to act could compromise passenger safety. However, "see one, do one, teach one" has been considered standard operating procedure in medical education for dozens of years. Finally, this model is beginning to change, transitioning to "see one, practice many, do one." Health care is one of the last high-stakes industries to adopt simulation as an andragogical tool to improve patient safety.
When implementing a simulation program, the initial question is WHY? Why are you embarking on a s... more When implementing a simulation program, the initial question is WHY? Why are you embarking on a simulation program? Is it for residency training, team performance improvement, or improvement of your unit workflow with identification of latent system errors? After the WHY is clearly defined, the subsequent questions, who, what, and where, are easily answered. WHO do you need to accomplish the predetermined goal, and how do you best engage them. The WHO includes identifying your learners, team members, and the stakeholders. All must be committed to ensure the program will be a success. Strategies to engage WHO vary and options are discussed. The WHAT encompasses the curriculum and equipment including creating a safe zone where learners can practice new and difficult skills without judgment. WHERE defines the site of the simulation whether it is a simulation lab, in situ on labor and delivery, or a classroom, each offering pros and cons. Strategies for a careful and thoughtful introduction of a simulation program are presented. Successful planning will ensure your effort will become an integral component of a comprehensive patient safety program.
Comprehensive Healthcare Simulation: Obstetrics and Gynecology, 2019
When implementing a simulation program, the initial question is WHY? Why are you embarking on a s... more When implementing a simulation program, the initial question is WHY? Why are you embarking on a simulation program? Is it for residency training, team performance improvement, or improvement of your unit workflow with identification of latent system errors? After the WHY is clearly defined, the subsequent questions, who, what, and where, are easily answered. WHO do you need to accomplish the predetermined goal, and how do you best engage them. The WHO includes identifying your learners, team members, and the stakeholders. All must be committed to ensure the program will be a success. Strategies to engage WHO vary and options are discussed. The WHAT encompasses the curriculum and equipment including creating a safe zone where learners can practice new and difficult skills without judgment. WHERE defines the site of the simulation whether it is a simulation lab, in situ on labor and delivery, or a classroom, each offering pros and cons. Strategies for a careful and thoughtful introduction of a simulation program are presented. Successful planning will ensure your effort will become an integral component of a comprehensive patient safety program.
Cesarean delivery is the most common surgery performed in the United States, accounting for appro... more Cesarean delivery is the most common surgery performed in the United States, accounting for approximately 32% of all births. Emergency Cesarean deliveries are performed in the event of critical maternal or fetal distress and require effective collaboration and coordination of care by a multidisciplinary team with a high level of technical expertise. It is not well understood how the physical environment of the operating room (OR) impacts performance and how specialties work together in the space.ObjectiveThis study aimed to begin to address this gap using validated techniques in human factors to perform a participatory user-centered analysis of physical space during emergency Cesarean.MethodsThis study employed a mixed-methods design. Focus group interviews and surveys were administered to a convenience sample (n = 34) of multidisciplinary obstetric teams. Data collected from focus group interviews were used to perform a task and equipment analysis. Survey data were coded and mapped...
The Joint Commission Journal on Quality and Patient Safety, 2020
OBJECTIVE A pilot study was conducted in a tertiary referral center to assess whether wearing cap... more OBJECTIVE A pilot study was conducted in a tertiary referral center to assess whether wearing caps labeled with providers' names and roles has an impact on communication in the operating room (OR). METHODS Two obstetricians observed surgeries for name uses and missed communications. Following each case, all providers were given a short survey that queried their attitude about the use of labeled surgical caps, their ability to know the names and roles of other providers during a case, and the impact of scrub attire on identifying others. They were also asked to rate the ease of communication and their ability to recall name and roles of the personnel specific to the case. Patients were asked how they perceived the use of labeled caps by providers. RESULTS Twenty scheduled cesarean deliveries were randomized to either labeled (10) or nonlabeled (10) surgical caps. A total of 129 providers participated in the study, with 117 providing responses to the survey. Providers reported knowing the names and roles of colleagues more often with labeled caps vs. nonlabeled caps (names: 77.8% vs. 55.0%, 95% confidence interval [CI] = 64.4%-88.0% vs. 41.6%-67.9%, p = 0.011; roles: 92.5% vs. 78.3%, 95% CI = 81.8%-98.0% vs. 65.8%-88.0%, p = 0.036). Name uses increased (43 vs. 34, p = 0.208), and missed communications decreased (16 vs. 20, p = 0.614) when labeled caps were worn. Providers and patients had an overwhelmingly positive response to labeled caps. CONCLUSION This pilot study demonstrated that wearing labeled caps in the OR led to more frequent name uses and less frequent missed communications. Providers and patients embraced the concept of labeled caps and perceived wearing labeled caps as improving communication in the OR.
American Journal of Obstetrics and Gynecology, 2011
To determine whether adhesions at first repeat cesarean delivery predicts skin incision to neonat... more To determine whether adhesions at first repeat cesarean delivery predicts skin incision to neonatal delivery times. STUDY DESIGN: This is a secondary analysis of a prospective cohort study of women who underwent a first repeat CD. Immediately following a first repeat cesarean delivery, surgeons scored the severity and location of adhesions. Surgeons were asked to categorize adhesions as none, filmy, or dense, and to identify their presence among specified locations including uterus, fascia, omentum, bowel, and "other". We then summed weighted scores for each patient based on the presence and type of adhesions at each site: 0 (no adhesions),
Simulation in healthcare : journal of the Society for Simulation in Healthcare, 2008
The leading causes of pregnancy-related death are embolism (20%), hemorrhage (17%), and pregnancy... more The leading causes of pregnancy-related death are embolism (20%), hemorrhage (17%), and pregnancy-induced hypertension (16%).The Obstetric and Mechanical Engineering Departments at Stanford University worked together to create inexpensive devices that were used in high fidelity simulations to replicate 2 of the leading causes of maternal mortality: hemorrhage and eclampsia (seizure). The mechanisms were designed to behave as similarly as possible to a human patient. The engineering team designed the eclampsia mechanism to jostle the mannequin's head at a frequency and randomness that matched those observed in human generalized seizures. The hemorrhage mechanism was designed to give visual and tactile cues similar to the actual physiology of a pregnant uterus. Both devices were remote controlled. The hemorrhage mechanism was used in a scenario of an amniotic fluid embolism with severe postpartum hemorrhage. The final flow rate was adjustable between 525 and 600 mL/min. The traine...
Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 2014
Objectives The management of the critically ill obstetric patient is an essential component in th... more Objectives The management of the critically ill obstetric patient is an essential component in the training of an emergency medicine (EM) resident physician. Due to advances in the quality of perinatal care, many obstetric emergencies such as eclampsia and postpartum hemorrhage, are infrequently encountered in the emergency department. Other conditions such as peripartum cardiac arrest requiring perimortem cesarean section, are such rare occurrences that most residents will never experience such a case during their training. Nonetheless, EM residents must acquire the knowledge and skills to appropriately diagnose and manage a broad spectrum of obstetric emergencies. In recent years, the potential role for simulation in obstetrics training has become increasingly apparent. Simulation has been shown to improve the confidence and performance of Obstetrics and Gynecology residents.1-2 However, the use of simulation-based obstetrics training programs in EM residencies has not been described. We have developed and successfully implemented a multi-modal simulation-based curriculum to educate EM residents in the management of uncommon yet critical obstetric emergencies. Description An experienced group of educators from the specialties of Emergency Medicine and Obstetrics and Gynecology gathered to design and implement a simulation-based obstetrics course for EM resident trainees. The 2013 Model of the Clinical Practice of Emergency Medicine was used to determine the educational goals for the curriculum, with the focus on “critical” obstetric conditions that are encountered during the peripartum period.3 Three different simulation modalities were employed to provide instruction on the selected obstetric emergencies. High-fidelity manikin scenarios, paired with structured debriefing, were used to simulate cases of peripartum cardiac arrest and postpartum hemorrhage. Management strategies for eclampsia and chest pain in pregnancy were reviewed in a mock oral board examination format. Skills stations with task trainers were used to discuss the approach to uterine atony, vaginal delivery with a nuchal cord, shoulder dystocia, and breech delivery. Nine PGY-2 EM residents participated in this course. Anonymous pre- and post-course surveys were distributed assessing the participants’ confidence levels before and after completing the course as well as their satisfaction with the course. Conclusion Overall, residents felt more confident in managing obstetric emergencies after completing this simulation-based course. They reported statistically significant post-course improvements in confidence levels in managing postpartum hemorrhage (P=0.023), myocardial infarction in pregnancy (P<0.001), and peripartum cardiac arrest (P<0.001), as well as the indications for performing a perimortem cesarean section (P<0.001). Participants also demonstrated statistically significant improvements in confidence in recognizing and managing shoulder dystocia (P=0.005) and delivering a fetus in breech presentation (P<0.001). Feedback from residents was overwhelmingly positive. This course has been taught to one class of residents at a single residency program. At this time, it is unknown if participating in the course improves performance. In the future, this course will become a required component of the residency’s educational curriculum and may even be implemented at other simulation centers. It will be important to formally evaluate the impact of the course on improving resident clinical and technical skills. This multi-modal simulation-based curriculum provides a comprehensive approach to training EM residents to manage critically ill obstetric patients in the emergency department. References 1. Hirakoa M, Kamikawa G, McCartin R, Kaneshiro B. A pilot-structured resident orientation curriculum improves the confidence of incoming first-year obstetrics and gynecology residents. Hawaii J Med Pub Health 2003;72:387-390. 2. Daniels K, Arafeh J, Clark A, Waller S, Druzin M, Chueh J. Prospective randomized trail of simulation versus didactic teaching for obstetrical emergencies. Simul Healthc 2010;5:40-45. 3. Counselman FL, Borenstein MA, Chisholm CD, Epter ML, Khandelwal S, Kraus CK, Luber SD, Marco CA, Promes SB, Schmitz G, Keehbauch JN. The 2013 model of the clinical practice of emergency medicine. Acad Emerg Med 2014;21:574-598. Disclosures None
Communication and teamwork deficiencies have been identified as major contributors to poor clinic... more Communication and teamwork deficiencies have been identified as major contributors to poor clinical outcomes in the labor and delivery unit. In response to these findings, multidisciplinary simulation-based team training techniques have developed to focus specifically on skills training for teams. The evidence demonstrates that multidisciplinary simulation-based team training minimizes poor outcomes by perfecting the elusive teamwork skills that cannot be taught in a didactic setting. Multidisciplinary simulation-based team training is also being used to detect latent system errors in existing or new units, to rehearse complicated procedures (surgical dress rehearsal), and to identify knowledge gaps of labor and delivery teams. Multidisciplinary simulation-based team training should be an integral component of ongoing quality-improvement efforts to ultimately produce teams of experts that perform proficiently.
Uploads
Papers by Kay Daniels