p

How to Integrate Findings from SimulationExercises to Improve Obstetrics Care in the InstitutionPaul Preston, MD,* Connie Lopez, RNC, MSN, CNS,† and Nancy Corbett, RN, BSN, MHA‡

The opening of a new facility often brings teams from different backgrounds who havepreviously never worked together. Organizational goals of safety and high reliability fromthe first day of operations would be impossible to attain without testing. Simulation is nowbeing used to test new services, departments, and entire facilities before opening. This hasbeen accomplished by establishing a well-developed program of in situ simulation withstrong physician and nursing educator co-leads and simulation teams. This article de-scribes a process for testing through simulation and the systemic findings from testingexisting and new facilities and services.Semin Perinatol 35:84-88 © 2011 Elsevier Inc. All rights reserved.

KEYWORDS simulation, healthcare systems, perinatal, team training

Kaiser Permanente (KP) is a large, integrated health care de-livery system. It was founded in 1945 and currently serves

more than 8.6 million members, delivering approximately100,000 babies each year. In 2002, the Perinatal Patient SafetyProgram, a multifaceted program, was introduced to improvemultidisciplinary communication, teamwork, and operationalsystems on perinatal units consistent with high reliability orga-nizations.

KP has been using clinical simulation training in itsperinatal areas for more than 10 years to enhance thePerinatal Patient Safety Program. Research supports theconcept that practicing obstetrical emergencies improvesperinatal outcomes1 and is a critical part of highly reliable

erinatal units.2

Over time, through these simulations, there have beenmultiple opportunities to identify and fix significant sys-tems problems that impede safe care. All simulations areperformed by multidisciplinary teams. The use of multi-disciplinary teams in the simulations was thought to benecessary because the true management of maternal andneonatal patients requires a cohesive team response.

*Department of Anesthesia, Regional TPMG Safety Educator, Kaiser Perma-nente San Francisco Medical Center, San Francisco, CA.

†Simulation-based Education, Training National Risk Management and Pa-tient Safety, Kaiser Permanente Program Offices, Oakland, CA.

‡Perinatal Patient Safety, Regional Risk Management, Northern California,Kaiser Permanente, Oakland, CA.

Address reprint requests to Paul Preston, MD, Department of Anesthesia,Regional TPMG Safety Educator, Kaiser Permanente San FranciscoMedical Center, 2425 Geary Blvd, San Francisco, CA 94115. E-mail:

Paul.Preston@kp.org

84 0146-0005/11/$-see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1053/j.semperi.2011.01.008

Simulations are based on internal KP and external riskdata,2 focusing on emergencies such as Cesarean deliveries,failed intubations, massive hemorrhage, shoulder dystocia,eclampsia, high spinal anesthesia, and maternal cardiac ar-rest. Along with the success of rehearsing emergencies onexisting clinical units, KP has evolved its simulation programto include the testing of new services and facilities. For ex-ample, the organization recently opened a new Women’s andChildren’s Center. This type of systems testing was thoughtto be necessary because regardless of the large investment ininfrastructure,3 there is no guarantee of a successful under-taking. Potential for patient harm caused by the unfamiliarityof the team with the new environment and systems is aninherent risk to the organization unless the system is carefullytested. Simulations that are organized for new services andfacilities therefore provide a unique opportunity for real-timetesting of the new environment and the systems that supportthat environment, before opening. In the following sectionswe will explore the findings from simulation in existing facil-ities and those in completely new facilities.

Benefit of In Situ SimulationThe experience in KP has almost entirely been with in situ,full-team drills. This reflected a practical reality: with a hugeworkforce and widely spread clinical units, the cost and dis-ruption of a central simulation facility would have been pro-hibitive. Despite the potential disruptions of clinical care andthe occasional cancelation of simulation activities as the re-

sult of real emergencies, we found this to be an effective way

fotiet

waqqetfll(ctdihw

Integrating findings from simulation exercises to improve OB 85

to train teams. In the process, it became apparent that a greatdeal of systems data was being generated and the need toaddress and improve on facility specific emergency responseswould not have surfaced in a simulation laboratory.

Simulation to AddressSystem Issues Both Beforeand After the Unit Is OpenSimulation for systems issues can be very different from tra-ditional crew resource management or task training simula-tions. The latter involves considerable curricular planning,prereading, and the use of checklists to ensure that learningand skills targets are met for participants and teams. Debrief-ings are focused on attainment of predetermined educationalgoals as well as team and personal insights. All of these can bevery helpful in providing an optimal educational experience.

In contrast, the goal of systems testing is learning about theworking environment. It can be very challenging for evenseasoned teams and providers to anticipate the potential is-sues and shortcomings in a new facility. Simulated scenariosshould be realistic clinical emergencies, with the stated goalbefore the scenario being identification of strengths andweaknesses of the facility and what could be changed toimprove safety. The data collected may include individualskill or teamwork opportunities but will largely be composedof systemic problems that interfere with the teams getting thejob done. The real work is in triaging the identified problemsby frequency and likelihood of severe harm, assigning thepotential owners, and proposing potential fixes and time-lines. However, the rewards of these efforts in safety, team-work, confidence in leadership, and a sense of unit owner-ship are profound. With this in mind, the following arecategorized into the type of finding (physical or collaborativepractice) and the age of the unit (existing or new). Physicalissues include the hospital facility and the equipment andsystems that support care, while collaborative practice issuesencompass interdisciplinary and interdepartmental plans,agreements and communications.

Physical: Existing UnitsCommunication via efficient call systems is a critical factor inobstetrical safety. Emergencies in the labor and delivery de-partment (L&D) almost always require a team for optimalmanagement, but the wide varieties of emergencies that oc-cur require very different responses. These may have notbeen recognized in unit construction, but need to be sup-ported by well designed call systems. We find that 4 separatecall buttons are optimal but often are not provided. First, acall button is needed for patient requests of staff. Second, anemergency nursery button is needed that rings directly to theintensive care nursery and signals outside the patient room. Itwas determined this nursery call button should be positionedclose to the infant warmer, not at the head of the mother’sbed. Third, a staff assist button is needed that rings in alllabor rooms and at the nursing station, signaling the room

originating the call so the team can assemble at the bedside c

immediately for any obstetrical emergencies. Finally, it wasdetermined a code blue button that rings throughout thefacility is needed in the rare event of a maternal collapse. Inresponse to such discoveries, one hospital in the system com-pletely rewired the internal call system to provide these ca-pabilities.

Other findings often involved security measures that hadbeen applied without the involvement of clinicians. In somecases, the doors and stairwells to the unit had been locked tosecure the unit from potential infant abduction attempts andunauthorized entries. Unfortunately, this also prevented theaccess of critical emergency responders, such as anesthesiaand the code team, and has been a causal factor in reportedsentinel events. Solutions included the use of a loud alarmbells on the doors, which would allow security while alsoallowing emergency entry by staff. Other facilities had pad-locked emergency carts used for neonatal resuscitation. Insimulation debriefing, clinicians stated their frustrations withthese controls, and related times when care had been delayedwith potential consequences. A better practice was the use oftamper evident, breakable seals to fulfill regulations and al-low immediate access. Another finding was a failure to pro-vide elevator override keys for rapid patient transport. Theseand other simple interventions could be readily applied inour existing units.

Physical: New UnitsDespite their high cost, new facilities may fail to fully meetthe needs of patients and staff, and staff may fail to appreciatethe best use for what has been built. Some of this is attribut-able to a gap in knowledge and skills. The professionals whodesign and build new hospitals often have no experience inproviding patient care.3 Conversely, health care workers haveew skills or expertise in the legal and practical considerationsf facility construction. It is not practical to assume that doc-ors and nurses could read a blueprint and translate the visualmage into facility flow and functionality, particularly duringmergency situations. Simulation is proving to be a powerfulool in bridging this gap.

One consistent finding in new units was the challenge oforking in increased physical space. Our health care facility

rchitects and designers responded to staff and patients re-uests for larger, private birthing rooms that resemble a high-uality hotel room. Although each patient room is betterquipped to handle the tasks of childbirth, infant resuscita-ion and labor analgesia, the resulting increase in total squareootage makes for much larger prenatal units. There wereonger distances from some rooms to the nursing station,onger transports from the L&D room to the operating roomOR), and the migration of critical units, such as the intensiveare nursery, to other floors in the new facility. In one facility,he emergency department and blood bank were now in aifferent building from the labor unit. The staff at these facil-

ties had not anticipated the implications these changes mightave on previous workflows. Collaborative agreements onhen to call for help and exactly where to manage emergen-

ies needed considerable revision. Physical issues involved

bnrmewibt

Mlatff

gwutfrleit

nrdtdictspd

twfcL

86 P. Preston, C. Lopez, and N. Corbett

understanding and using the electronic call systems insteadof just crying out for assistance, and a need for enhancedability to manage emergencies in the labor rooms. Havingworked through these concerns, staff was able to enjoy themany benefits of working in a large, new and spacious unit.

New Equipment EMRThe effects of an all electronic medical record (EMR) havealso been a major focus of KP’s in situ simulations. The EMRimproves safety and reliability in numerous areas, such aslegibility, medication safety and complete access to patientrecords. However, the EMR also demands focused attention,while profoundly altering workflows.4,5 Although this may

e of little consequence in some clinical areas, the change inormal processes seemed to matter a great deal in the obstet-ical area. The most critical human factor that needed to beaintained in L&D was overall situational awareness. How-

ver, when clinicians were working on the computer, theyere not watching the fetal monitors, a problem that has

ncreased with EMR implementation. Several strategies haveeen developed to assure that situational awareness is main-ained:

1. Multidisciplinary shift change reports and intrashifthuddles were critical to increase and maintain situa-tional awareness. Before providers log onto the com-puter, they are expected to attend reports and are madeaware of the big picture, to anticipate which patientsmight need additional surveillance. Peer expectationsare also critical in supporting these communicationhabits.

2. A system was also established to clearly identify whichprovider was responsible for which patient. In this case,bracelets were handed from nurse to nurse when leav-ing for breaks or at the end of a shift, creating a tangiblemarker of responsibility for a particular patient.

3. Another systemic fix to enhance situational awarenessfor the entire unit was to provide a 52 inch screen todisplay fetal heart rate in common work areas, high-lighting critical data with a conspicuous display

ost clinicians overestimate their ability to multitask. Simu-ation offers a perfect forum to demonstrate the difficulty ofnalyzing critical new data while concurrently charting onhe EMR. Simulation has allowed staff to analyze delays andailures and reinforce concepts and practices to improve per-ormance.

Interestingly, the greatest risk times appear to be with ur-ent, rather than emergent, situations and during high unitorkload. During true emergency cases, documentation issually done retrospectively on the EMR and is not a distrac-ion. During routine cases, there is time to work through theairly comprehensive and involved EMR process, saving cur-ent data. However, during urgent cases (eg, precipitous de-ivery on admission) or cases with escalating urgency, allfforts focus on rapidly running through the EMR processnstead of dealing with the clinical situation. This was found

o be the time of most profound loss of vigilance. w

Collaborative PracticeTesting for Established UnitsOne significant and far-reaching benefit of conducting criti-cal event team training in situ is the ability to identify systemsissues with the multidisciplinary team and then develop col-laborative practice agreements as a solution.

One of the first collaborative practice agreements cameearly on with in situ simulation. In most prenatal units wheresimulation was done, there was an uncoordinated dash to theOR for an emergency Cesarean delivery. The bed was bangedagainst the door frame along with intravenous (IV) and epi-dural pumps, all the lines (IV, epidural, IV fluid line used foramnioinfusion) were tangled, leading to smashed staff toesand fingers. However, on one unit, the move was smooth andwell coordinated. It was observed that the L&D nurse dis-connected all the lines and pumps and proceeded to the ORwith just the mainline. Her transfer strategy was dissemi-nated across all prenatal units. This resulted in one of the firstinterdisciplinary practice agreements with anesthesia, obstet-rics and nursing. Now, in an emergency move, all medica-tions are disconnected and the patient is transferred withonly the main line IV. The IV bag is placed on the bed,requiring no extra IV pumps or poles for transfer. Anesthesiaagreed to restart any necessary medications once in the OR.This change in practice has made transfers more efficient andsafe for staff, decreasing the chance of dislodging the main-line IV and eliminating any inadvertent bolus of medications,such as magnesium sulfate and pitocin. Another learningmoment came from a real-life case in which anesthesia stafftried to induce emergency general anesthesia through an IVfluid line used for amnioinfusion as the result of tangled lines.The collaborative practice now includes removal of all extra-neous lines.

Another important collaborative practice agreement thatresulted from in situ critical event team training is use of the“1-2-3 Minute Rule.” This is a standardized algorithm defin-ing what actions need to take place in the first, second, andthird minute with a fetal bradycardia.6 In the first minute, the

urse assesses if the heart rate is the mother’s or baby’s heartate. In the second minute, the nurse checks the patient toetermine if a delivery is imminent or if the patient needsransfer to the OR. During the third minute, if the bradycar-ia persists, the nurse calls for an emergency cesarean and

nitiates transport to the OR before the arrival of the physi-ian. This algorithm ensures that the patient is moved rapidlyo the right location. The physician can always cancel theurgery if the fetal heart rate recovers. These collaborativeractices are trained and reinforced with in situ simulationrills.In situ simulations have also been used to test response

imes to emergencies. One medical center had several caseshere women delivered in the elevator on the long transfer

rom the emergency department (ED) to L&D. This medicalenter has no elevator override for emergencies. The ED and&D departments wanted to change practice and test

hether they could safely deliver in the ED by mobilizing the

Integrating findings from simulation exercises to improve OB 87

perinatal team to the ED. They found by using the stairs thatthe perinatal team could get to the ED in �60 seconds. Afterrunning several drills and upgrading equipment in the ED,the ED staff now evaluates all laboring women for precipitousdelivery and if necessary the delivery occurs in the ED withthe perinatal team present.

In-situ simulation has been used to teach the importanceof fire safety in the L&D units. One medical center developeda very elaborate scenario for fire in the OR, which includedthe local city fire department. The scenario was made realisticby the use of dry ice, which created the impression of smokecreeping in to the OR. Participants were anticipating a sce-nario, such as maternal hemorrhage, but instead had to dealwith a fire. Years later, this scenario has still left an impressionon all the participants. They know how to use the fire extin-guisher, how to pull the fire alarm, and where the fire exitsare located. Realistic scenarios can make for long-lastingawareness and learning.

One practice seen in most of our L&D units is consistentpreference of one OR over another. Many units have one ORthat is poorly laid out or understocked (often referred to asthe “dog”), and, as a result, staff will use the preferred OR asoften as possible. Through in situ simulations, units learnthey needed a collaborative practice agreement to use thenonpreferred OR for all scheduled Cesarean and nonurgentCesarean, leaving the best OR for emergencies.

Through in situ simulations of emergency cesarean deliv-eries, roles and responsibilities for the nurses have been re-fined and practiced. Typically, 3 nurses respond to an emer-gency cesarean and are assigned to their nursing zone. NurseA, the primary nurse’s zone is at the head of the bed and isresponsible for assisting anesthesia with the Airway. NurseB’s zone is assigned to the patient’s Body and is responsiblefor the prep, Foley catheter and positioning. Nurse C’s zone isthe surgery table area and is responsible for circulating du-ties, helping the OB technician set-up the table and conduct-ing the counts. OR rooms have been redesigned to ensure allOR supplies are located in the appropriate nursing zones,reducing confusion and cross contamination.

Testing for New Facilities and ServicesIn 2009, a new freestanding Women and Children’s Hospitalwas opened after 12 days of in situ testing. Budgeted orien-tation costs were used for multidisciplinary simulations totest new systems and orient staff to the new hospital. Eventhough experienced teams were moving from the old to thenew facility, unexpected systems issues were discovered, re-quiring changes in emergency plans for the new units.

Staff had to plan for a longer run down the hall to the OR.At a basic level, this meant early detection of an emergency,calling for help and quickly mobilizing the team. Manage-ment of obstetrical emergencies required new collaborativepractice agreements. In the older facility, the working planfor an asphyxiated infant was to quickly transport the new-born a few feet away to the intensive care nursery. Similarly,the plan for maternal hemorrhage on the postpartum unit

was rapid transport to the L&D OR. Teams at the new larger

facility quickly realized during the in situ simulation thatbecause of the new facility layout, their normal processeswere not going to be optimal. Infant resuscitation would nowneed to take place in the labor suite or OR. The postpartumward for mothers and babies was now on a completely dif-ferent floor from L&D. Maternal resuscitation needed to oc-cur on postpartum floor before transfer to the OR. Theseissues were clearly delineated during one scenario on themom/baby unit: while the OB physician was pulling the bedout of the room for a ride on the elevator to another floor,anesthesia was pulling the bed back into the room. Anesthe-sia was adamant they needed to intubate an unstable motherbefore an elevator ride. During debriefing, the team discov-ered their old processes were not going to work at the newfacility. Simulation provided the opportunity to develop, testand reinforce new emergency practices in the new locations.

In 2009, one hospital became a trauma center, the first forthe organization. Several days of simulation were conductedto test the ED’s ability to handle emergency trauma OB sce-narios. One scenario involved a motor vehicle accident withserious injuries to the mother requiring immediate surgeryand delivery of a premature baby. This scenario involvedmany departments, starting with admission of the motherthrough the ED, transfer to the main OR, and mobilization ofthe intensive care nursery team to the main OR for delivery ofthe baby. This multidepartmental simulation had never beenattempted before, but the medical center felt it was impera-tive to test the ability to mobilize care most efficiently andexpeditiously.

OpportunitiesWith the opening of a new facility, it is important to ask thequestion, “What processes would cause harm if the systemsfail?” From day one, it is vital that critical processes workcorrectly. Simulation provides the opportunity to test newsystems and processes and to practice new workflows, suchas calling personnel for emergencies.

Planning for emergencies and rare events should not waitto be “worked out” once a new facility opens. In situ simula-tion offers the perfect opportunity to test, retest and train staffbefore any real emergency. In situ simulation is a collabora-tive quality improvement process, with continual interven-tions to optimize systems for safe and high-quality patientcare.7

Beyond emergencies, in situ simulation allows the oppor-tunity to orient staff to their new work environment. Simu-lation helps to test and answer common questions.

Where are the supplies now located?How have workflows changed?How long does it now take to get patients from one unit to

another?What is the new process for calling for help and how long

does it take?

This bolsters teamwork and helps support the transition to

the new facility.

88 P. Preston, C. Lopez, and N. Corbett

Because staff orientation time is part of the start-up budgetfor new services, leadership was interested in testing the ideaof whether simulation could lead to more effective use oforientation time in a cost neutral way. It was found thatorientation dollars budgeted for the use of traditional meth-ods for opening a new facility were more than adequate tocover the expense of in situ simulation. The conclusion wasusing simulation for orientation has the potential to producebetter outcomes at no added cost.

ChallengesThe authors found partnering with leadership essential to thesuccess of implementing simulations, especially for large-scale simulation endeavors. Leadership buy-in and contin-ued support is essential to the success of any program. Allfacilities that participate in the Perinatal Patient Safety Pro-gram require executive leadership commitment to improvingpatient safety by supporting all elements of the program. Allfacility executive leaders sign a Memorandum of Understand-ing defining this commitment.

Partnering with leadership achieves initial buy-in, but forcontinued operational support and program sustainability, aneffective process for documenting results that demonstrates areturn on investment is essential. To document and share theprograms results, KP has created an internal national databaseavailable to all regions to place standardized, simulation-basedcurriculum and collect data on the success of their programs.We have found the most successful programs are those that aresupported by both regional and local leadership. We attributethe sustainability of our Perinatal Patient Safety Program to thiscommitment from all levels of the organization.

Implementing in situ simulations to test systems also canbe challenging. KP has found that the most efficient use ofresources for a simulation training day is a 4-hour simulation

training paired with a 4-hour regular shift. Each team works

4 hours and then simulates 4 hours allowing the training of 2separate teams in an 8-hour interval.

ConclusionsMost of our system changes (larger units with more space,electronic medical records, and automated drug dispensingsystems), address some problems but create new issues, mak-ing training and testing imperative. The goal is to embed insitu simulation as an on-going event in the system. Simula-tion is a realistic method to test existing and new systems andservices while building teams, reinforcing human factorsskills, improving communications and producing high-qual-ity patient care.

References1. Draycott T, Sibanda T, Owen L, et al: Does training in obstetrics emer-

gencies improve neonatal outcomes? BJOG 113:177-182, 20062. Knox GE, Simpson DR, Garite TJ: High reliability perinatal units; an

approach to the prevention of patient injury and medical malpracticeclaims. J Health Risk Mgmt 19:24-32, 1999

3. Colliver V: Kaiser has ambitious plans/HMO to spend more than $10billion to build renovate medical buildings. San Francisco Chronicle,September 11, 2005 http://articles.sfgate.com/2005-09-11/business/17388730_1_northern-california-hospitals-kaiser-s-oakland-hospital-kaiser-permanente-plans. Accessed January 13, 2011

4. Ash JS, Berg CE: Some unintended consequences of information tech-nology in health care: The nature of patient care information system-related errors. J Am Med Inform Assoc 11:104-112, 2004

5. Andersen P, Lindgaard AM, Prgomet M, et al: Mobile and fixed computeruse by doctors and nurses on hospital wards: Multi-method study on therelationships between clinician role, clinical task, and device choice.J Med Internet Res 11:e32, 2009

6. MacEachin SR, Powell KJ, Lopez CM, et al: The fetal heart rate collabor-ative practice project; Situational awareness in electronic fetal monitor-ing—A Kaiser Permanente perinatal safety program initiative. J PerinatalNeonatal Nurs 23:314-323, 2009

7. Herzer KR, Rodriguez-Perez JM, Doyle PA, et al: A practice frameworkfor patient care teams to prospectively identity and migrate clinical haz-

ards. TJC J Qual Patient Safe 35:72-81, 2009