Available online at www.sciencedirect.com

www.elsevier.com/locate/semperi

S E M I N A R S I N P E R I N A T O L O G Y 3 7 ( 2 0 1 3 ) 1 5 1 – 1 5 6

0146-0005/13/$ - seehttp://dx.doi.org/10

nCorresponding autBristol, Chilterns, WHealth, Southmead

E-mail address:

Simulation: Improving patient outcomes

Abi Smith, MBCHBa,n, Dimitrios Siassakos, MDb, Joanna Crofts, MDb, andTim Draycott, MD, FRCOGa

aDepartment of Women’s Health, Southmead Hospital, Bristol, UKbRiSQ (Research into Safety and Quality), School of Clinical Sciences at the University of Bristol, Chilterns, UK

A R T I C L E I N F O

Keywords:

Simulation

Teamwork

Training

Obstetrics

Patient outcomes

front matter & 2013 Else.1053/j.semperi.2013.02.0

hor. Abi Smith, MBCHB,omen’s Health, SouthmeHospital, Westbury on Tabi.c.smith@gmail.com (

a b s t r a c t

Effective training has been shown to improve perinatal care and outcome, decrease litigation

claims and reduce midwifery sick leave. To be effective, training should be incentivised, in a

realistic context, and delivered to inter-professional teams similar to those delivering actual

care. Teamwork training is a useful addition, but it should be based on the characteristics of

effective teamwork as derived from the study of frontline teams. Implementation of simulation

and teamwork training is challenging, with constraints on staff time, facilities and finances.

Local adoption and adaptation of effective programmes can help keep costs down, and make

them locally relevant whilst maintaining effectiveness. Training programmes need to evolve

continually in line with new evidence. To do this, it is vital to monitor outcomes and robustly

evaluate programmes for their impact on patient care and outcome, not just on participants.

& 2013 Elsevier Inc. All rights reserved.

Obstetric emergencies are rare and it is axiomatic that they

should be managed by experienced staff, and indeed this is

almost ubiquitously recommended. However, experience is

difficult to acquire because of the rarity of cases, but may be

gained in part through simulation.

Simulation permits individual health professionals and

teams to inculcate skills and cultures in preparation for safe

effective clinical care, whilst gaining confidence and becom-

ing more efficient. Simulation is an educational device, not a

place or a technology; it can be simple or complex.

However, we should not overestimate the effect of simu-

lation; a recent review of simulation-based medical education

(SBME) recognised that some, but not all, SBME was associ-

ated with improvements in clinical outcome.1 There is an

important need to test whether obstetric simulation training

programmes are effective, sustainable and cost-effective.

1. Background

Women,2 their families and insurers3 value safety in labour

as highest of all priorities. However, in 2008 the UK-based

vier Inc. All rights reserv05

RiSQ (Research into Safead Hospital, Westbury onrym, Bristol BS10 5NB, UKA. Smith).

Kings Fund report ‘safe births: everybody’s business’4

observed that whilst the overwhelming majority of births in

England are safe, some births are less safe than they could,

and should, be. These safety failings are extraordinarily

expensive. Substandard care and its sequelae cost the National

Health Service £3.1 billion ($5 billion) in the decade 2000–20103;

individual, family and societal costs notwithstanding.

Improving maternal and perinatal care is also a global

priority; the World Health Organization (WHO) has estimated

that 1500 women die every day from preventable complica-

tions of pregnancy and childbirth.5 Worldwide, there are

approximately 4 million neonatal deaths each year6 and

approximately 3 million third trimester stillbirths.7 Improving

maternal and neonatal mortality is the focus for two of the

Millennium Development Goals.5

The investigation of the root cause of maternal and peri-

natal deaths provides a consistent set of lessons, including

failure to recognise, failure to seek senior input, poor team

working and the requirement to improve the skills of the

team,8–10 but also problems in staff–patient communication.

UK-based research showed that over 25% of new mothers

ed.

ty and Quality), School of Clinical Sciences at the University ofTrym, Bristol BS10 5NB, United Kingdom, Department of Women’s.

S E M I N A R S I N P E R I N A T O L O G Y 3 7 ( 2 0 1 3 ) 1 5 1 – 1 5 6152

were not satisfied with communication by the medical staff

and there was a significant association between satisfaction

with communication by medical staff and overall satisfaction

with care.11

The identification of these common problems has lead to

repeated recommendations for obstetric emergency training,

particularly simulation-based training. Training can poten-

tially reduce preventable harm by up to 50–70%8 and

improved simulation-based training for intrapartum care is

at least part of the solution, but it must be both effective and

sustainable. This article will review the current evidence for

effective obstetric emergency training and discuss the prac-

ticalities and feasibility of running and evaluating obstetric

simulation training programmes.

2. Evidence of effectiveness

Improved multi-professional training appears to be one of the

most promising strategies to improve perinatal outcomes

across the world, localised for best fit. However training is

not automatically effective and we must be certain that

training improves outcomes. A systematic review of obstetric

emergencies training published in 2003 concluded that few

methods of obstetric skills training had been evaluated, and

there was minimal evidence of their effectiveness.12

However, since 2003 there have been numerous studies

published evaluating the effectiveness of skills training for

obstetric emergencies, often using simulation. Out of these

sometimes contrary studies, we are developing an evidence

base for simulation-based training in obstetrics and in many

ways obstetric simulation is leading the way for evidence in

SBME. This is particularly true for modified Kirkpatrick level 4

interventions13that result in changes to the organisation or

delivery of care and more importantly patient outcomes.

In the UK, the SaFE Study was a multi-factorial Randomised

Controlled Trial (RCT) comparing in-hospital and simulation-

centre training, with or without additional Crew Resource

Management (CRM)-style teamwork training conducted.

Training was evaluated using multiple-choice question-

naires14 and videoed simulated obstetric emergencies

(eclampsia, post-partum haemorrhage and shoulder dysto-

cia) before training and 3 weeks, 6 months and 12 months

following training. The results showed that local in-hospital

training improved the knowledge, skills and attitudes of

individual midwives and doctors, and the clinical perform-

ance of teams for at least 1 year following training.15–17

Training in a simulation centre, or the addition of CRM-

style teamwork training, did not have any extra benefit over

local in-hospital clinical training alone.

Similarly, a large multicentre RCT demonstrated no impact

of CRM training alone on patient outcome in the USA,

although CRM and placebo groups both improved signifi-

cantly.18 Another multicentre RCT showed that improve-

ments in adverse outcome were possible only when

teamwork training was combined with clinical simulation

training.19

The training in the SaFE Study was based on the multi-

professional simulation course set up at Southmead Hospital,

Bristol, UK in 2000. Following its introduction, number of

infants born with a 5-min Apgar score of less than 7

decreased from 86.6 to 44.6 per 10,000 births. The incidence

of Hypoxic Ischaemic Encephalopathy decreased from 27.3 to

13.6 per 10,000 births.20 There were also significant improve-

ments in the management of shoulder dystocia, associated

with a decrease in neonatal injury (brachial plexus injury and

fractures of the humerus or clavicle) by 75% (RR ¼ 0.25, 95%

CI 0.11–0.57).21 The management of cord prolapse also

improved with a fall in median diagnosis–delivery interval

from 25 to 14.5 min (p o 0.001) after training and a consistent

improvement in neonatal outcomes.22 These data support

the notion that annual, in-hospital, multi-professional simu-

lation-based training for all staff can increase the effective-

ness and efficiency of the maternity team and can result in

improved clinical outcomes.

Other training programmes have also been associated with

improvements in clinical outcomes in obstetric emergencies.

In America, Phipps et al., described a team-training pro-

gramme with a simulation component. The majority of staff

were trained over a 6-month period. The training had institu-

tional backing with champions to support it on the labour

and delivery unit. The mean Adverse Obstetric Index (AOI)

score decreased from 0.052 pre-training (95% CI 0.048–0.055)

to 0.043 post-training (95% CI 0.040–0.047).23 In Chicago, the

introduction of a training programme focusing on adherence

to the clinical protocol for shoulder dystocia was associated

with improved documentation and a significant reduction in

brachial plexus injury at birth from 10.4% to 2.6% (p ¼ 0.03)

and at discharge from 7.8% to 1.3% (p ¼ 0.04).24

In Canada, the Society of Obstetricians and Gynaecologists

of Canada launched an obstetric patient safety programme

‘Managing Obstetric Risks Efficiently’ (MOREOB) in 2002.

MOREOB includes in-hospital, multidisciplinary hands-on

skills simulation training, interactive discussions and

problem-solving exercises. By 2007, the programme had

extended to 126 hospitals in five provinces that provide care

for 48% of the births in Canada. In the first 3 years there was a

significant reduction in variance of care between and within

institutions, and a noted culture change in all practice

settings. Using liability claims information from the hospi-

tals, a reduction trend has been observed in hospital incurred

costs.25

In the Netherlands, a retrospective cohort study investi-

gated the use of peri-mortem caesarean section (PMCS)

between 1993 and 2008 following the introduction of Manag-

ing Obstetric Emergencies and Trauma (MOET) training in

2004. The rate of PMCS increased after the introduction of

training from 12% to 35%.26 Despite this increase in the use of

the PMCS, maternal outcomes remained poor. A systematic

review of maternal cardiac arrests from 1980 to 2010 showed

that PMCS was performed in 87.2% of cases. Of the 94 PMCSs,

only four were initiated within the recommended 4 min.27

Maternal cardiac arrest is a rare event and it is unlikely that

an optimum time frame for PMCS can ever be definitively

set.28 Observations of simulated scenarios have highlighted

slow recognition, failure to initiate CPR, failure to displace

uterus and poor communication.29 Focus should therefore be

shifted towards training teams to recognise maternal cardiac

arrest and to deliver timely, high-quality resuscitation.28 Such

training can be useful in low-resource settings as well.

S E M I N A R S I N P E R I N A T O L O G Y 3 7 ( 2 0 1 3 ) 1 5 1 – 1 5 6 153

A programme in Tanzania recently demonstrated the

potential for simulation to improve patient outcome in low-

resource settings. An emergency obstetric course was deliv-

ered to healthcare providers in a tertiary unit. There was an

increase in the active management of the third stage follow-

ing training, with 0.6% of women receiving an oxytocic drug

at delivery of the baby prior to training and 25.1% following

training. The relative risk of appropriate active management

following training was therefore 42.8 (confidence interval

13.7–133.5). Uterine massage, bimanual compression and

oxytocin infusion also increased significantly following

training.30

Other training programmes may not have demonstrated

improvements in clinical outcomes, but have been associated

with other significant changes that are important for

patients, staff and healthcare organisations alike. For exam-

ple, the introduction of an in-house multi-professional

obstetric emergency training programme in Copenhagen,

Denmark was associated with a 45% reduction in midwifery

sick leave.31 Perhaps feeling more able to cope with emergen-

cies may reduce staff stress and associated illness. A large

cohort study of 28,561 nurses found that the quality of

teamwork affected a nurse’s decision to leave the profession,

with poor-quality teamwork being associated with a five-fold

increase in a nurse’s intention to leave. As the quality of

teamwork improved, a nurse’s intent to leave the profession

decreased significantly.32

3. Active components of training

A review of obstetric training programmes, most commonly

employing simulation, that were associated with improve-

ment in clinical outcomes was published in 2009.33 Common

features of clinically effective training programmes were:

�

multi-professional training,

�

training of all staff in an institution,

�

training staff locally within the unit in which they work,

�

integrating teamwork training with clinical teaching,

�

use of high-fidelity simulation models and

�

institution-level incentives for training (eg, reduced hos-

pital insurance premiums).33

These common features merit some further elucidation as

they may help institutions, units and funders understand the

secrets of successful simulation-based training.

3.1. Incentives to participate in training

Implementing and subsequently running an in-hospital,

obstetric simulation training programme is demanding and

requires more than altruism and a handful of enthusiasts.

Staff require dedicated time to develop and facilitate training

within their institutions, and over the course of a year, the

entire workforce needs to be released from clinical duties to

attend training. Simulation training also requires equipment,

although not always the most expensive equipment. Release

of staff, funding of training equipment and refreshments for

participants cost hospitals money. Establishing an in-hospital

obstetric emergency simulation programme is very difficult

without institutional support, both financially and at board

level. It is therefore unsurprising that all the training pro-

grammes associated with improvements in clinical outcomes

have had institutional support. The main driver for institu-

tional support of training appears to be financial, in the form

of reduced insurance premiums. Institutions can then justify,

or offset, the cost of running training directly from these

reduced insurance premiums1–3,21,23,31 and the insurers will

recoup their investment downstream.

For medical insurers, obstetric care is a good place to start

because of the following reasons:

�

Single specialty with 60% of litigation and

compensation costs.

�

Risks/costs are known.

�

Data are routinely collated.

�

Interventions are proven and evidence based.

�

Clinicians & professional bodies are engaged.

Moreover, returns on investments are likely to be demon-

strated in 1 year, and can be extrapolated into ‘claims made’

savings within 3–5 years.

Therefore financial pump priming from medical insurers,

with evidence of clinical effect, is essential to many

simulation programmes and should be employed more

widely still.

3.2. In-house training

There may be multiple barriers, such as cost, time away from

work and staff attitude, to successful team training. These

barriers may be more easily overcome by implementing ‘in-

house’ drills, particularly when such drills are part of a safety

agenda. The SaFE study investigated the difference between

local and simulation-centre training and showed that there

was no additional improvement from training off site in a

simulation centre.3,4,14,17

Several units have adopted training in-house as it may be

cheaper than using a simulation centre, whilst others have

employed a hub-and-spoke model of local training supported

by a simulation centre-based cadre of trainers. Local training

also facilitates identification of potential improvements in

local systems, for example in equipment or in the layout of

rooms.5,6,22,31

3.3. Realistic simulation

In parallel with the increased uptake and evaluation of

simulation training in obstetrics and midwifery, there has

been an increase in the number of mannequins and practical

aids available for training. In their 2008 review, Gardner and

Raemer compared 20 commercial maternity training aids

manufactured by eight different companies.8,34 These train-

ing aids ranged from the low-cost, simple pelvis simulators to

expensive, whole-body simulators.

Training equipment, however, is often expensive and can

be difficult to transport and use. In 2009 an evidence-for-

action call to reduce intrapartum-related deaths was pub-

lished.9,35 The paper suggested that ‘significantly lower cost,

S E M I N A R S I N P E R I N A T O L O G Y 3 7 ( 2 0 1 3 ) 1 5 1 – 1 5 6154

durable, easy to disassemble and sanitise, high-fidelity man-

nequins with culturally appropriate features’ were required

to reduce intrapartum-related deaths in low-resource

settings.

Training mannequins need to be fit for purpose. High-

fidelity training mannequins were associated in the SaFE

study with a higher, and faster, successful delivery rate, in

simulated shoulder dystocia.10,15 Moreover, shoulder dystocia

training with a high-fidelity mannequin was associated with

a 70% reduction in neonatal injury in one hospital,11,21

whereas training with a low-fidelity mannequin was associ-

ated with an increase in neonatal injury in another.8,36

Realism is not necessarily synonymous with ‘high technol-

ogy’. How closely the real situation is represented is key in

whether a simulation is high fidelity or not.12,37 For example,

effective communication with women and their companions

is essential in maternity care.14,38 Training with a patient-

actor, or a patient-actor with a mannequin (hybrid simula-

tion), can increase the realism of the situation and improve

communication between healthcare professionals and

patients.15,16,39,40

3.4. Inter-professional team training with integratedteamwork

The SaFE study demonstrated a significant improvement in

clinical performance, and team behaviour during simulation

after training in teams. However, there was no significant

difference in knowledge, clinical performance or team behav-

iour between learners who had received additional isolated

teamwork training, imported from the aviation industry and

those who were randomised to clinical training alone. The

patient-actor perception of care was also not influenced by

the addition of specific teamwork training based on

aviation.14,17

Some clinical teams possess characteristics that make

them more efficient than others, and so are better able to

achieve good outcomes by performing key actions in a timely

manner. However, these characteristics are not explained by

differences in knowledge or skill,18,41 clinical training needs

to emphasise teamwork.

Teamwork is key in improving outcomes, therefore identi-

fying the actions that improve performance may be impor-

tant in developing more efficient teams. A portfolio of mixed-

methods studies identified that more efficient teams, which

administered magnesium sulphate in the management of

eclampsia within the allocated time (10 min), were likely to

have: 19,38

�

stated (recognised and verbally declared) the emergency

earlier,

�

managed the critical task using closed-loop communica-

tion (task clearly and loudly delegated, accepted, executed

and completion acknowledged) and

�

had significantly fewer exits from the labour room com-

pared with teams who did not and used a structured form

of communication.

These sorts of skills should be taught during training and

where they have been integrated into training there have

been associated improvements in decision–delivery intervals

and neonatal outcomes after urgent (within 30 min)

births.20,22

4. Sustainability of simulation training

Current evidence suggests that any obstetric simulation

training programme should contain certain themes to be

clinically effective.21,33 The challenge of sustainability

remains.

In order to implement in-house training for all staff there

has to be a clear institutional commitment. There must be a

continued programme of training along with recruitment and

retention of high-quality trainers. It is essential to have a

highly relevant and organised curriculum delivered using the

appropriate simulators. This will motivate staff to attend

training. A constructive learning environment is vital without

the threat of summative assessment.22,42

Delivering this training in a clinical environment is chal-

lenging. It is difficult to run training on a busy delivery

ward.23,43 There are also issues around the availability of

trainers, acquisition of the correct simulators and facilities

both for training and debriefing.24,42 However, with the

correct components, it is possible.

5. The way forward

There are currently increasing pressures and expectations on

services. It is therefore extremely important to ensure that

staff are working effectively and are well supported in doing

this. Simulation-based training can provide teams with

increasing confidence to manage emergency situations.

Importantly, if teams train within their own environment,

they identify local solutions to local problems, facilitating a

more productive working environment.25,33 Providing staff

with feedback on patient outcomes following training can

also enhance motivation.26,43

Training should continually evolve to ensure maximum

effectiveness and also to adapt skills to emerging clinical

problems, as identified through local or national enquiries,8,27

for example sepsis, which is now the single largest cause of

direct maternal death in the UK. Timely identification and

management of critically ill septic mothers is challenging due

to the physiological adaptations of pregnancy. Therefore, it is

vital that staff are equipped with the tools to diagnose and

manage sepsis efficiently and effectively.28

5.1. Develop new methods to teach teamwork

Whereas teamwork methods based on aviation have not

shown impact on patient outcome when used for training

maternity staff, recent work shows that good teamwork is

necessary for optimal team performance in managing obstet-

ric adverse events. A few simple behaviours make a differ-

ence between a team that is efficient and effective, and one

that is not, and these simple behaviours can, and should, be

taught within clinical context. Because different trainees

have different learning styles, teamwork training methods

S E M I N A R S I N P E R I N A T O L O G Y 3 7 ( 2 0 1 3 ) 1 5 1 – 1 5 6 155

should be derived from the comprehensive study of mater-

nity teams in simulation and real-life, and should be diverse

enough to cover the learning needs for junior and senior staff

alike.29,44

5.1.1. Monitor care and outcomesOutcomes that improved once may deteriorate again.28,45

Systems need to be in place to detect lapses and address

them with targeted interventions. The NHS White Paper

‘Equity and Excellence’30,46 outlines an ambition to empower

both patients and professionals to ‘focus on continuously

improving those things that really matter to patients—the

outcome of their healthcare’. A reduction in preventable harm

is a priority for both the patients and families and the NHS

and, in part, this requires early identification of adverse

trends.

We must make measurement of outcomes easier, timelier

and more understandable in order to make rapid quality

improvement and targeted training feasible.31,47 Robust

maternity data are routinely collected for all births in the

UK.32,48 However, some of the data collected lack known

interventions for improving care and there is no standardised

collection of indicators for maternity care, which makes it

difficult to benchmark performance and set standards.33,49 In

addition, there is no easy way of converting the existing data

into information that NHS managers, clinical staff and

patients can use to reduce preventable harm. Recently, an

expert Delphi panel based at the RCOG in the UK has

recommended and defined a common data set of 12 indica-

tors that could be universally collected and displayed as a

‘dashboard’ easily accessible to all frontline staff.33,49

5.1.2. Evaluate with appropriate designsSignificant progress has been made at establishing an evi-

dence base for obstetric emergency training since the pub-

lication of Black and Brocklehurst’s paper in 2003.12 However,

at present almost all studies that associate obstetric simu-

lation training with improvements in clinical outcomes are

retrospective and report neonatal outcome data. There is very

limited evidence to suggest that obstetric emergency training

improves maternal clinical outcomes. We should employ the

same robust methodological techniques to investigate train-

ing as we do all the other interventions employed in clinical

obstetrics.

The next stage would be a well-designed RCT to test the

effect of training on both maternal and neonatal outcomes

across several hospitals while adjusting for baseline differ-

ences and temporal changes. It would also be anticipated to

do more good than harm, so equipoise might not apply;

making traditional study designs, such as a parallel rando-

mised controlled trial, potentially unethical. Finally, there

would be logistical and pragmatic difficulties in establishing

training across several units (clusters) within a short time.

Whereas a cluster design was possible for SaFE, that study

was examining short- or medium-term effects using simu-

lation for a sample of staff, and not the clinical effects of

training for whole units, so the logistical difficulties were

fewer. A suitable design would be a stepped-wedge rando-

mised trial, where the clusters all receive the intervention but

they are randomised in the order they receive it. This design

controls for temporal changes and allows the evaluation of

longer-term effects while reducing the risk of bias by using

each cluster as its own control. It is also less prone to loss of

power than simple cluster designs, but it can be statistically

complicated to analyse and expensive to set up.50

6. The future of obstetric simulation training

Reducing preventable harm is a priority for accoucheurs,

women and insurers across the globe. Intrapartum skills

training appears to offer a direct route to improvement,

however the effect of intrapartum training programmes has

been at least inconsistent, if not conflicting.

More and better research should be undertaken to inves-

tigate training and in particular the effect of training at scale.

The reduced morbidity and mortality burden from better care

means that funding will follow proof.

There is an accruing evidence base for intrapartum skills

training and also the characteristics of effective training.

Therefore with the current evidence, intrapartum training

should be local, multi-professional, mandatory for all staff

and ideally supported by institutional (most often insurance

based) incentives to train.

7. Disclosure

The authors declared the following potential conflicts of

interest with respect to the research, authorship and/or

publication of this article: TJD is trustee and DS and JFC are

members of the PROMPT Maternity Foundation, a UK-based

charity running training courses. They have no financial

interest from this association.

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