Didactic and Simulation Nontechnical Skills Team Training to Improve Perinatal Patient Outcomes in a Community Hospital

Virtual simulation training for postpartum hemorrhage in low-to-moderate-volume hospitals in the US

Background

Maternal mortality in the United States is rising and many deaths are preventable. Emergencies, such as postpartum hemorrhage, occur less frequently in non-teaching, rural, and urban low-birth volume hospitals. There is an urgent need for accessible, evidence-based, and sustainable inter-professional education that creates the opportunity for clinical teams to practice their response to rare, but potentially devastating events.

Objective

To assess the feasibility of virtual simulation training for the management of postpartum hemorrhage in low-to-moderate-volume delivery hospitals.

Study design

The study occurred between December 2021 and March 2022 within 8 non-academic hospitals in the United States with low-to-moderate-delivery volumes, randomized to one of two models: direct simulation training and train-the-trainer. In the direct simulation training model, simulation faculty conducted a virtual simulation training program with participants. In the train-the-trainer model, simulation faculty conducted virtual lessons with new simulation instructors on how to prepare and conduct a simulation course. Following this training, the instructors led their own simulation training program at their respective hospitals. The direct simulation training participants and students trained by new instructors from the train-the-trainer program were evaluated with a multiple-choice questionnaire on postpartum hemorrhage knowledge and a confidence and attitude survey at 3 timepoints: prior to, immediately after, and at 3 months post-training. Paired t-tests were performed to assess for changes in knowledge and confidence within teaching models across time points. ANOVA was performed to test cross-sectionally for differences in knowledge and confidence between teaching models at each time point.

Results

Direct simulation training participants (n=22) and students of the train-the-trainer instructors (n=18) included nurses, certified nurse midwives and attending physicians in obstetrics, family practice or anesthesiology. Mean pre-course knowledge and confidence scores were not statistically different between direct simulation participants and the students of the instructors from the train-the-trainer course (79%+/-13 versus 75%+/-14, respectively, P-value=.45). Within the direct simulation group, knowledge and confidence scores significantly improved from pre- to immediately post-training (knowledge score mean difference 9.81 [95% CI 3.23-16.40], P-value<.01; confidence score mean difference 13.64 [95% CI 6.79-20.48], P-value<.01), which were maintained 3-months post-training. Within the train-the-trainer group, knowledge and confidence scores immediate post-intervention were not significantly different compared with pre-course or 3-month post-course scores. Mean knowledge scores were significantly greater for the direct simulation group compared to the train-the-trainer group immediately post-training (89%+/-7 versus 74%+/-8, P-value<.01) and at 3-months (88%+/-7 versus 76%+/-12, P-value<.01). Comparisons between groups showed no difference in confidence and attitude scores at these timepoints. Both direct simulation participants and train-the-trainer instructors preferred virtual education, or a hybrid structure, over in-person education.

Conclusion

Virtual education for obstetric simulation training is feasible, acceptable, and effective. Utilizing a direct simulation model for postpartum hemorrhage management resulted in enhanced knowledge acquisition and retention compared to a train-the-trainer model.

The Impact of an Intern's Clinical Guidebook on Easing the Transition of New Interns Into the United States Healthcare System

This study explores the efficacy of an intern's clinical guidebook in facilitating the transition of categorical internal medicine interns into the United States healthcare system. New interns, particularly foreign medical graduates, face multifaceted challenges during their initial year of residency. The research, conducted at Ascension Saint Joseph Hospital in Chicago, employed a quasi-experimental pre-post design involving 20 interns. Participants were provided with an intern's clinical guidebook, and their knowledge was assessed through pre and post exams. Results demonstrated a statistically significant improvement in overall knowledge, with mean scores increasing from 65% to 77.37%. Subgroup analysis revealed similar improvements among both male and female interns. Data confidentiality and ethical considerations were prioritized, with participant data anonymized and stored securely. Despite limitations, this study highlights the guidebook's potential to enhance intern education and improve the quality of care provided during the crucial transition period. Further research is recommended to validate and extend these findings.

The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis

INTRODUCTION

Little is known about the optimal simulation-based team training in obstetric emergencies. We aimed to review how simulation-based team training affects patient outcomes in obstetric emergencies.

MATERIAL AND METHODS

Search Strategy: MEDLINE, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were searched up to and including May 15, 2021.

SELECTION CRITERIA

randomized controlled trials (RCTs) and cohort studies on obstetric teams in high-resource settings comparing the effect of simulation-based obstetric emergency team training with no training on the risk of Apgar scores less than 7 at 5 min, neonatal hypoxic ischemic encephalopathy, severe postpartum hemorrhage, blood transfusion of four or more units, and delay of emergency cesarean section by more than 30 min.

DATA COLLECTION AND ANALYSIS

The included studies were assessed using PRISMA, EPCO, and GRADE.

RESULTS

We found 21 studies, four RCTs and 17 cohort studies, evaluating patient outcomes after obstetric team training compared with no training. Annual obstetric emergency team training may reduce brachial plexus injury (six cohort studies: odds ratio [OR] 0.47, 95% CI 0.33-0.68; one RCT: OR 1.30, 95 CI% 0.39-4.33, low certainty evidence) and suggest a positive effect; but it was not significant on Apgar score below 7 at 5 min (three cohort studies: OR 0.77, 95% CI 0.51-1.19; two RCT: OR 0.87, 95% CI 0.72-1.05, moderate certainty evidence). The effect was unclear for hypoxic ischemic encephalopathy, umbilical prolapse, decision to birth interval in emergency cesarean section, and for severe postpartum hemorrhage. Studies with in situ multi-professional simulation-based training demonstrated the best effect.

CONCLUSIONS

Emerging evidence suggests an effect of obstetric team training on obstetric outcomes, but conflicting results call for controlled trials targeted to identify the optimal methodology for effective team training.

Institutionalizing an interprofessional simulation education program: an organizational case study using a model of strategic change

Initiatives to implement interprofessional simulation education programs (ISEP) often fail due to lack of support, resources from management or proper integration into the organization system. This paper aims to identify factors that ensure the successful implementation of an ISEP. Further, the study explores the potential effects an ISEP can have on organizational processes and culture. The case study describes the implementation process of an ISEP in a non-academic community hospital using interviews, participative observations and archival data over six years. A thematic approach has been used to analyze the data guided by Kotter's 8-step model for organizational change. Strategies for a successful implementation of an ISEP include: 1) make a case for interprofessional simulation-based education (SBE), 2) search for healthcare champions, 3) define where the ISEP will lead the organization, 4) spread the word about interprofessional SBE, 5) ensure that structures, skills and supervisors align with the change effort, 6) win over smaller entities, 7) enable peer feedback and create more change, 8) institutionalize the ISEP. Indicators of how the ISEP impacted hospital culture are presented and discussed. ISEPs - if implemented effectively - provide powerful opportunities to span boundaries between professional groups, foster interprofessional collaboration, and eventually improve patient care.

Formal Assessment of Teamwork Among Cancer Health Care Professionals in Three Large Tertiary Centers in Nigeria

PURPOSE

There are strategies to bring quality cancer care to underserved patients, but poor use of the principles of teamwork is a major barrier to achieving quality services. The intent of this study was to assess teamwork as perceived by health care workers caring for patients with cancer.

METHODS

We conducted a survey among health care professionals in cancer care at 3 tertiary centers in southwestern Nigeria from July to November 2016. Respondents rated teamwork using the Safety Attitudes Questionnaire; we focused on the teamwork climate subscale comparing health care providers and institutions using analysis of variance and on collaboration using logistic regression.

RESULTS

Three hundred seventy-three professionals completed the survey: 177 physicians (47%), 51 nurses (14%), 21 pharmacists (6%), 31 laboratory technicians (8%), and 88 others (24%); 5 (1%) participants had missing professional information. The average teamwork climate score across all professionals in the study was 70.5 (SD = 24.2). Pharmacists rated the teamwork climate the lowest, with a mean score of 63.9 (SD = 29.5); nurses and laboratory technicians rated teamwork higher, with means of 74.5 (SD = 21.7) and 74.2 (SD = 27.1), respectively; and physicians rated teamwork 66.0 (SD = 23.6). Collaboration with other health care providers was reported as poorer by physicians compared with nurses and pharmacists.

CONCLUSION

Although overall teamwork scores were consistent with ambulatory studies in the United States, important subgroup variations provide targets for intervention. Physicians rated collaboration as poor both intra- and interprofessionally. Pharmacists rated interprofessional teamwork with nurses as poor. Efforts to transform cancer care must focus on building trust among the key stakeholders. This is critical in low-resource settings, which must maximize the use of limited resources to improve patient outcomes.

Using simulation team training with human's factors components in obstetrics to improve patient outcome: A review of the literature

OBJECTIVE

to assess the evidence from multidisciplinary simulation team training in obstetrics that integrates human's factors components on patient outcome.

INTRODUCTION

It has been stated that simulation-based education has the potential to improve technical and nontechnical skills. Reports from enquiries into maternal and newborn adverse outcomes, highlight that the majority of incidents are due to a breakdown of communication and a lack of crisis resource management skills (CRM). It is therefore reasonable to think that a better training on teamwork based on simulation will ultimately improve obstetrics care. In order to explore further that idea, we conducted a literature review on patient outcome after a multidisciplinary simulation training in obstetrics.

METHOD

Pubmed, Advances in health sciences education, BMC in medical education, BMC in pregnancy and Childbirth, BMJ open, BMJ Simulation and technology enhanced learning were searched from inception to May 2020 for full-text publications in English on interprofessional, multidisciplinary, obstetrics, simulation training, non-technical skills, CRM. Searches were limited to studies with a report on patient outcome after a multidisciplinary simulation program that included elements of CRM.

RESULT

Out of the ten studies selected in our review, five were single site before and after prospective studies and five were cluster before and after randomized trials. All the single site studies reported a positive outcome in low and high resource countries. Three single site studies reported a reduction between 41 and 50 % of blood transfusion after simulation team training. Two single studies reported a reduction of maternal mortality by 34 % and a decrease in an adverse obstetrics index outcome from 0.052 to 0.048 with a p-value of 0.05. Cluster studies showed either no change or some improvement in patient outcomes such as a 37 % improvement on weighted obstetrics adverse outcome, a 17 % reduction in the incidence of PPH and a 47 % reduction in the incidence of retained placenta. Stillbirths rate was reduced by 34 % while newborn deaths was down by 62 %. There was also a 15 % reduction of maternal mortality in favor of the trained team after adjustment to the secular mortality trend. Neonatal death from 24 weeks during the first 24 h was also reduced by 83 % in the intervention site compare with an increase by 18 % in the control site.

CONCLUSION

There is evidence that simulation team training that includes CRM is associated with better patient outcome. In order to consolidate this finding, appropriate methodology should be used in future studies with the support of health authorities.

The COMET framework: A novel approach to design an escape room workshop for interprofessional objectives

While recreational escape rooms have gained momentum across education and team training in multiple professions, few published escape room designs have been truly interprofessional. A major obstacle faced by educators and team leaders alike is the lack of any practical design framework for escape room development that is specific to meeting learning objectives. The COMET Framework (Context, Objectives, Materials, Execution, and Team Dynamics) was developed as a step-by-step approach to escape room design using general terminology and piloted in a one-hour workshop at a regional interprofessional conference. Surveys completed by participants suggest that application of the COMET framework increased understanding and confidence regarding escape room design regardless of prior experience with the format. The generality of the COMET framework may allow it to be utilized for team exercise design more broadly in the contexts of interprofessional training and faculty development.

Does Multidisciplinary Team Simulation-Based Training Improve Obstetric Emergencies Skills?

Clinical simulation in obstetrics has turned out to be a tool that can reduce the rate of perinatal morbidity and mortality. The objective of this study was to analyze the impact and evaluate the effects of training with high-fidelity simulation of obstetric emergencies on a multidisciplinary group. The quasi-experimental research study was structured in three phases: a first phase where the most important obstetric emergencies were determined, a second phase of design and development of the selected cases for simulation training, and a third and final phase where the abilities and satisfaction of the multidisciplinary team were analyzed. Three scenarios and their respective evaluation tools of obstetric emergencies were selected for simulation training: postpartum hemorrhage, shoulder dystocia, and breech delivery. The health professionals significantly improved their skills after training, and were highly satisfied with the simulation experience (p < 0.05). An inter-observer agreement between good and excellent reliability was obtained. Regarding conclusions, we can state that high-fidelity obstetric emergency simulation training improved the competencies of the health professionals.

National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse's role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women's Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.

Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance

BACKGROUND

Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care.

OBJECTIVES

To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience.

SEARCH METHODS

The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes.

MAIN RESULTS

We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries. Kirkpatrick level 4 (patient outcome) Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence) Kirkpatrick level 3 (performance in practice) We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions).

AUTHORS' CONCLUSIONS

Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.

Simulations of Deliveries of SARS-CoV-2 Positive Pregnant Women and Their Newborn Babies: Plan to Implement a Complex and Ever-Changing Protocol

Management of severe acute respiratory Syndrome corona virus-2 (SARS-CoV-2) infected pregnant women at time of delivery presents a unique challenge. The variability in the timing and the method of delivery, ranging from normal vaginal delivery to an emergent cesarean section, adds complexity to the role of the health care providers in the medical care of the patient and in the interactions, they have with other providers. These variations are further influenced by the availability of isolation rooms in the facility and adequacy of personal protective equipment. The protocols already set in place can be further challenged when the facility reaches its capacity to manage the patients.To fulfill the goal of providing adequate management to the SARS-CoV-2 infected pregnant women and their infants, avoid variation from suggested guidelines, and decrease risk of exposure of the health care workers, the health care provider team needs to review the variations regularly. While familiarity can be achieved by reviewing the guidelines, clinical case simulations provide a more hands-on approach.Using case-based simulations and current guidance from the Center for Disease Control, American Academy of Pediatrics, and recent reviews, we discuss a management guideline developed at our institution to facilitate provision of care to SARS-CoV-2 infected pregnant women during delivery and to their infants, while protecting health care providers from exposure, and in keeping with the local facility logistics. KEY POINTS: · Simulation of delivery of SARS-CoV-2 positive pregnant women can minimize the risk of exposure to healthcare professionals.. · Four common scenarios of delivery as described can be adapted for the evolving guidelines for the management of SARS-CoV-2 positive pregnant women.. · Integrating simulations of management of SARS-CoV-2 positive pregnant women is feasible in daily clinical routine..

Measuring Real-Time Team Cognition During Team Training

OBJECTIVE

A method for detecting real-time changes in team cognition in the form of significant communication reorganizations is described. We demonstrate the method in the context of scenario-based simulation training.

BACKGROUND

We present the dynamical view that individual- and team-level aspects of team cognition are temporally intertwined in a team's real-time response to challenging events. We suggest that this real-time response represents a fundamental team cognitive skill regarding the rapidity and appropriateness of the response, and methods and metrics are needed to track this skill.

METHOD

Communication data from medical teams (Study 1) and submarine crews (Study 2) were analyzed for significant communication reorganization in response to training events. Mutual information between team members informed post hoc filtering to identify which team members contributed to reorganization.

RESULTS

Significant communication reorganizations corresponding to challenging training events were detected for all teams. Less experienced teams tended to show delayed and sometimes ineffective responses that more experienced teams did not. Mutual information and post hoc filtering identified the individual-level inputs driving reorganization and potential mechanisms (e.g., leadership emergence, role restructuring) underlying reorganization.

CONCLUSION

The ability of teams to rapidly and effectively reorganize coordination patterns as the situation demands is a team cognitive skill that can be measured and tracked.

APPLICATION

Potential applications include team monitoring and assessment that would allow for visualization of a team's real-time response and provide individualized feedback based on team member's contributions to the team response.

Outcomes Associated With Insertion of Indwelling Urinary Catheters by Medical Students in the Operating Room Following Implementation of a Simulation-Based Curriculum

PURPOSE

Catheter-associated urinary tract infection (CAUTI) is a priority quality metric for hospitals. The impact of placement of indwelling urinary catheter (IUC) by medical students on CAUTI rates is not well known. This study examined the impact of a simulation-based medical student education curriculum on CAUTI rates at an academic medical center.

METHOD

Patient characteristics, procedural data, and outcome data from all operating room IUC insertions from June 2011 through December 2016 at the Northwestern University Feinberg School of Medicine were analyzed using a multivariable model to evaluate associations between CAUTI and inserting provider. Infection data before and after implementation of a simulation-based IUC competency course for medical students were compared.

RESULTS

A total of 57,328 IUC insertions were recorded during the study period. Medical students inserted 12.6% (7,239) of IUCs. Medical students had the lowest overall rate of CAUTI among all providers during the study period (medical students: 0.05%, resident/fellows: 0.2%, attending physicians: 0.3%, advanced practice clinicians: 0.1%, nurses: 0.2%; P = .003). Further, medical student IUC placement was not associated with increased odds of CAUTI in multivariable analysis (odds ratio, 0.411; 95% confidence interval: 0.122, 1.382; P = .15). Implementation of a simulation-based curriculum for IUC insertion resulted in complete elimination of CAUTI in patients catheterized by medical students (0 in 3,471).

CONCLUSIONS

IUC insertion can be safely performed by medical students in the operating room. Simulation-based skills curricula for medical students can be effectively implemented and achieve clinically relevant improvements in patient outcomes.

Interventions to improve team effectiveness within health care: a systematic review of the past decade

BACKGROUND

A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.

OBJECTIVES

To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research.

METHODS

Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.

CONCLUSION

Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Variability in the systems of care supporting critical neonatal intensive care unit transitions

OBJECTIVE

Assess practices supporting care transitions for infants and families in the neonatal intensive care unit (NICU) using a model of four key drivers: communication, teamwork, family integration, and standardization.

STUDY DESIGN

Single-day audit among NICUs in the Vermont Oxford Network Critical Transitions collaborative addressing policies and practices supporting the four key drivers during admission, discharge, shift-to-shift handoffs, within hospital transfers, and select changes in clinical status.

RESULTS

Among 95 NICUs, the median hospital rate of audited policies in place addressing the four key drivers were 47% (inter-quartile range (IQR) 35-65%) for communication, 67% (IQR 33-83%) for teamwork, 50% (IQR 33-61%) for family integration, and 70% (IQR 56-85%) for standardization. Of the 2462 infants included, 1066 (43%) experienced ≥1 specified transition during the week prior to the audit.

CONCLUSIONS

We identified opportunities for improving NICU transitions in areas of communication, teamwork, family integration, and standardization.

Patient safety culture in maternity units: a review

PURPOSE

The purpose of this paper is to summarize studies that have examined patient safety culture in maternity units and describe the different purposes, study designs and tools reported in these studies while highlighting gaps in the literature.

DESIGN/METHODOLOGY/APPROACH

Peer-reviewed studies, published in English during 1961-2016 across eight electronic databases, were subjected to a narrative literature review.

FINDINGS

Among 100 articles considered, 28 met the inclusion criteria. The main purposes for studying PSC were: assessing intervention effects on PSC (n=17), and assessing PSC level (n=7). Patient safety culture was mostly assessed quantitatively using validated questionnaires (n=23). The Safety Attitude Questionnaire was the most commonly used questionnaire (n=17). Interventions varied from a single action lasting five weeks to a more comprehensive four year package. The time between baseline and follow-up assessment varied from 6 to 24 months. No study reported measurement or intervention costs, and none incorporated the patient's voice in assessing PSC.

PRACTICAL IMPLICATIONS

Assessing PSC in maternity units is feasible using validated questionnaires. Interventions to enhance PSC have not been rigorously evaluated. Future studies should report PSC measurement costs, adopt more rigorous evaluation designs and find ways to incorporate the patient's voice.

ORIGINALITY/VALUE

This review summarized studies examining PSC in a highly important area and highlighted main limitations that future studies should consider.

A framework for oral health care value-based payment approaches

BACKGROUND

Dental practice has remained relatively insulated from payment upheavals in the broader health care system. The prevailing value-based payment (VBP) models in health care are largely absent in oral health care. The authors present an oral health care value-based payment framework for dentistry.

METHODS

The authors developed a VBP framework for oral health care, which describes 9 distinct methods to create VBP approaches in dentistry. The framework is based on the Centers for Medicare & Medicaid Services Learning Action Network framework for health care payment reform.

RESULTS

The oral health care value-based payment framework includes 4 payment categories and 9 separate payment mechanisms. These 9 payment mechanisms range on a value continuum, each with different financial risks and rewards as well as distinct value implications.

CONCLUSIONS

Although dental practice has made extraordinary advances in restorative dentistry, payers and policy makers are advocating for greater value outcomes. VBP models seek to deliver better care more efficiently by means of providing oral health providers the resources needed to increase the value proposition. With relatively minor modifications in practice patterns, VBP models can be developed and implemented for oral health care.

PRACTICAL IMPLICATIONS

This article can be used as a road map to take steps toward oral health care VBP approaches. The framework highlights how dentistry can learn from payment reforms under way in the health care system and present a model for oral health care payment and care delivery reform, and provides recommendations to advance oral health care VBP.

"Getting Everyone on the Same Page": Interprofessional Team Training to Develop Shared Mental Models on Interprofessional Rounds

AIM

This study aimed to evaluate the effect of a team training program to support shared mental model (SMM) development in interprofessional rounds.

DESIGN AND PARTICIPANTS

A three-arm randomized controlled trial study was conducted for interprofessional teams of 207 health profession learners who were randomized into three groups.

PROGRAM DESCRIPTION

The full team training program included a didactic training part on cognitive tools and a virtual simulation to support clinical teamwork in interprofessional round. Group 1 was assigned to the full program, group 2 to the didactic part, and group 3 (control group) with no intervention. The main outcome measure was team performance in full scale simulation. Secondary outcome was interprofessional attitudes.

PROGRAM EVALUATION

Teamwork performance and interprofessional attitude scores of the full intervention group were significantly higher (P < 0.05) than those of the control group. The two intervention groups had significantly higher (P < 0.05) attitude scores on interprofessional teamwork compared with the control group.

DISCUSSION

Our study indicates the need of both cognitive tools and experiential learning modalities to foster SMM development for the delivery of optimal clinical teamwork performances. Given its scalability and practicality, we anticipate a greater role for virtual simulations to support interprofessional team training.

The effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital

BACKGROUND

Preparing healthcare providers to manage relatively rare life-threatening emergency situations effectively is a challenge. Training sessions enable staff to rehearse for these events and are recommended by several reports and guidelines. In this review we have focused on interactive training, this includes any element where the training is not solely didactic but provides opportunity for discussions, rehearsals, or interaction with faculty or technology. It is important to understand the effective methods and essential elements for successful emergency training so that resources can be appropriately targeted to improve outcomes.

OBJECTIVES

To assess the effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital on patient outcomes, clinical care practices, or organisational practices, and to identify essential components of effective interactive emergency training programmes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and ERIC and two trials registers up to 11 March 2019. We searched references of included studies, conference proceedings, and contacted study authors.

SELECTION CRITERIA

We included randomised trials and cluster-randomised trials comparing interactive training for emergency situations with standard/no training. We defined emergency situations as those in which immediate lifesaving action is required, for example cardiac arrests and major haemorrhage. We included all studies where healthcare workers involved in providing direct clinical care were participants. We excluded studies outside of a hospital setting or where the intervention was not targeted at practicing healthcare workers. We included trials irrespective of publication status, date, and language.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC) Group. Two review authors independently extracted data and assessed the risk of bias of each included trial. Due to the small number of studies and the heterogeneity in outcome measures, we were unable to perform the planned meta-analysis. We provide a structured synthesis for the following outcomes: survival to hospital discharge, morbidity rate, protocol or guideline adherence, patient outcomes, clinical practice outcomes, and organisation-of-care outcomes. We used the GRADE approach to rate the certainty of the evidence and the strength of recommendations for each outcome.

MAIN RESULTS

We included 11 studies that reported on 2000 healthcare providers and over 300,000 patients; one study did not report the number of participants. Seven were cluster randomised trials and four were single centre studies. Four studies focused on obstetric training, three on obstetric and neonatal care, two on neonatal training, one on trauma and one on general resuscitations. The studies were spread across high-, middle- and low-income settings.Interactive training may make little or no difference in survival to hospital discharge for patients requiring resuscitation (1 study; 30 participants; 98 events; low-certainty evidence). We are uncertain if emergency training changes morbidity rate, as the certainty of the evidence is very low (3 studies; 1778 participants; 57,193 patients, when reported). We are uncertain if training alters healthcare providers' adherence to clinical protocols or guidelines, as the certainty of the evidence is very low (3 studies; 156 participants; 558 patients). We are uncertain if there were improvements in patient outcomes following interactive training for emergency situations, as we assessed the evidence as very low-certainty (5 studies, 951 participants; 314,055 patients). We are uncertain if training for emergency situations improves clinical practice outcomes as the certainty of the evidence is very low (4 studies; 1417 participants; 28,676 patients, when reported). Two studies reported organisation-of-care outcomes, we are uncertain if interactive emergency training has any effect on this outcome as the certainty of the evidence is very low (634 participants; 179,400 patient population).We examined prespecified subgroups and found no clear commonalities in effect of multidisciplinary training, location of training, duration of the course, or duration of follow-up. We also examined areas arising from the studies including focus of training, proportion of staff trained, leadership of intervention, and incentive/trigger to participate, and again identified no clear mediating factors. The sources of funding for the studies were governmental, local organisations, or philanthropic donors.

AUTHORS' CONCLUSIONS

We are uncertain if there are any benefits of interactive training of healthcare providers on the management of life-threatening emergencies in hospital as the certainty of the evidence is very low. We were unable to identify any factors that may have allowed us to identify an essential element of these interactive training courses.We found a lack of consistent reporting, which contributed to the inability to meta-analyse across specialities. More trials are required to build the evidence base for the optimum way to prepare healthcare providers for rare life-threatening emergency events. These trials need to be conducted with attention to outcomes important to patients, healthcare providers, and policymakers. It is vitally important to develop high-quality studies adequately powered and with attention to minimising the risk of bias.

Maternal Quality Outcomes and Cost

The quality of maternal care in the United States is receiving increased attention due to rising rates of severe maternal morbidity and maternal mortality when compared with other developed countries. Many of these events are considered preventable. The lack of adoption of evidence-based maternal patient safety bundles and tool kits requires immediate attention. Maternal levels of care described by the American Congress of Obstetricians and Gynecologists requires increased focus so that women are in the appropriate facility to receive care. Perinatal care management, integrated behavioral health, and preconception care should be considered a preferred methodology to achieve optimal maternal outcomes.

Improving safety and reducing error in endoscopy: simulation training in human factors

Patient safety incidents occur throughout healthcare and early reports have exposed how deficiencies in 'human factors' have contributed to mortality in endoscopy. Recognising this, in the UK, the Joint Advisory Group for Gastrointestinal Endoscopy have implemented a number of initiatives including the 'Improving Safety and Reducing Error in Endoscopy' (ISREE) strategy. Within this, simulation training in human factors and Endoscopic Non-Technical Skills (ENTS) is being developed. Across healthcare, simulation training has been shown to improve team skills and patient outcomes. Although the literature is sparse, integrated and in situ simulation modalities have shown promise in endoscopy. Outcomes demonstrate improved individual and team performance and development of skills that aid clinical practice. Additionally, the use of simulation training to detect latent errors in the working environment is of significant value in reducing error and preventing harm. Implementation of simulation training at local and regional levels can be successfully achieved with collaboration between organisational, educational and clinical leads. Nationally, simulation strategies are a key aspect of the ISREE strategy to improve ENTS training. These may include integration of simulation into current training or development of novel simulation-based curricula. However used, it is evident that simulation training is an important tool in developing safer endoscopy.

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes

The improvement of surgical outcomes has been achieved working under the assumption that they are mainly the result of technical skills. This model, although correct, is not exhaustive and has left out many variables that affect outcomes, of which a number can be grouped under the label of non-technical skills, which is a subset of human factors. Non-technical skills are developed to facilitate a shared mental model between team members, teams and their operational environment. They include situation awareness, decision-making, communication, teamwork, leadership and performance-shaping factors. The importance of these non-technical skills has been highlighted during the investigations of severe accidents in many high-risk industries and healthcare. There is an almost untapped opportunity to improve outcomes focusing on non-technical skills because until recently there has been an under-investment of time and resources in this area compared with technical skills. This theoretical paper supports the adoption of a broader model of human performance as a function of technical and non-technical skills and the cultural and organisational context where these are at play. We also aim to highlight a pathway to increase the investment in non-technical skills following the most updated evidence.

The importance of non-technical performance for teams managing postpartum haemorrhage: video review of 99 obstetric teams

OBJECTIVE

Little is known about how teams' non-technical performance influences clinical performance in obstetric emergencies such as postpartum haemorrhage.

DESIGN

Video review - observational study.

SETTING

A university hospital (5000 deliveries) and a regional hospital (2000 deliveries) in Denmark.

POPULATION

Obstetric teams managing real-life postpartum haemorrhage.

METHODS

We systematically assessed 99 video recordings of obstetric teams managing real-life major postpartum haemorrhage. Exposure was the non-technical score (AOTP); outcomes were the clinical performance score (TeamOBS) and the delayed transfer to the operating theatre (defined as blood loss >1500 ml in the delivery room).

RESULTS

Teams with an excellent non-technical score performed significantly better than teams with a poor non-technical score: 83.7 versus 0.3% chance of a high clinical performance score (P < 0.001), 0.2 versus 80% risk of a low clinical performance score (P < 0.001), and 3.5 versus 31.7% risk of delayed transfer to the operating theatre (P = 0.008). The results remained robust when adjusting for potential confounders such as bleeding velocity, aetiology, time of day, team size, and hospital. The specific non-technical skills associated with high clinical performance were vigilance, role assignment, problem-solving, management of disruptive behavior, and leadership. Communication with the patient and closing the loop were of minor importance. All performance assessments showed good reliability: the intraclass correlation was 0.97 (95% CI 0.96-0.98) for the non-technical score and 0.84 (95% CI 0.76-0.89) for the clinical performance score.

CONCLUSION

Video review offers a new method and new perspectives for research in obstetric teams to identify how teams become effective and safe; the skills identified in this study can be included in future obstetric training programmes.

TWEETABLE ABSTRACT

Non-technical performance is important for teams managing postpartum haemorrhage; video review of 99 obstetric teams.

A high-fidelity, fully immersive simulation course to replicate ENT and head and neck emergencies

Background

Simulation-based training has a fundamental role in medical education as it allows the learner to gain experience managing emergencies in a safe, controlled environment.

Methods

This 1-day course consisted of eight high-fidelity simulation scenarios, followed by a video-assisted debrief focusing on the technical and non-technical (communication skills, teamwork, leadership and situational awareness) aspects of managing ENT and head and neck emergencies.

Results

Eight courses have run since June 2014. Post-course questionnaires demonstrated that candidates’ confidence scores in managing airway and head and neck emergencies increased following completion of the course (p < 0.0001).

Conclusion

This was the first fully immersive ENT simulation course developed in the region. The learning objectives for each scenario were mapped to the ENT Intercollegiate Surgical Curriculum Programme. Feedback from the course indicated a continued demand for this style of training, leading to its inclusion in the training calendar.

Debriefing Interprofessionally: A Tool for Recognition and Reflection

As the health care environment increases in complexity and patient acuity rises, health profession graduates need to be prepared to work collaboratively to improve patient outcomes. The interprofessional debriefing tool (Debriefing Interprofessionally: Recognition & Reflection) presented in this article allows any simulation to be transformed into an interprofessional learning opportunity. The debriefing tool frames questions for both uniprofessional and multiprofessional simulation and is aligned with the Core Competencies for Interprofessional Collaborative Practice and with Quality and Safety Education for Nurses.

Promoting experiential learning through the use of high-fidelity human patient simulators in midwifery: A qualitative study

BACKGROUND

 The need to use innovative teaching and learning strategies in the nursing pedagogy is important in the 21st century. The challenges of clinical sites and opportunities for nursing students to gain clinical experience are a growing concern for many nurse educators. High-fidelity human patient simulators (HFHPS) are computerised mannequins that replicate a real-life patient, and when integrated into classroom teaching they allow students to become fully immersed into an almost real-life scenario.

OBJECTIVES

 The aim of this study was to describe how HFHPS can promote experiential learning following the management of postpartum haemorrhage as a midwifery clinical emergency.

METHOD

 A descriptive qualitative research approach was carried out in this study. The research setting was a local university in KwaZulu-Natal. The total population included all (N = 43) fourth-year baccalaureate of nursing undergraduate student midwives who participated as observers and/or role-players of a scenario role-play. An all-inclusive sampling was performed. There were 43 student midwives involved in the simulation teaching session with 6 of these students actively participating in each role-play at a time, while the remaining 37 observed. This occurred in two separate sessions and all the student midwives were involved in a debriefing session. These student midwives were then followed up and asked to participate in a focus group. The data in this article came from two separate focus groups which comprised 20 student midwives in total. Data were analysed using content analysis.

RESULTS

 Four categories emerged from the data, namely HFHPS offers a unique opportunity for student midwives to manage complex real-life emergencies; promotes reflection by allowing student midwives to reflect or review their roles, decisions and skills; allows student midwives to learn from their own experiences and encourages student midwives to try out what they learnt in a real-life situation.

CONCLUSION

 High-fidelity human patient simulators can be used in a complex case scenario to promote experiential learning of a clinical emergency.

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care

BACKGROUND

The Safety Program for Perinatal Care (SPPC) seeks to improve safety on labor and delivery (L&D) units through three mutually reinforcing components: (1) fostering a culture of teamwork and communication, (2) applying safety science principles to care processes; and (3) in situ simulation. The objective of this study was to describe the SPPC implementation experience and evaluate the short-term impact on unit patient safety culture, processes, and adverse events.

METHODS

We supported SPPC implementation by L&D units with a program toolkit, trainings, and technical assistance. We evaluated the program using a pre-post, mixed-methods design. Implementing units reported uptake of program components, submitted hospital discharge data on maternal and neonatal adverse events, and participated in semi-structured interviews. We measured changes in safety and quality using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators.

RESULTS

Forty-three L&D units submitted data representing 97,740 deliveries over 10 months of follow-up. Twenty-six units implemented all three program components. L&D staff reported improvements in teamwork, communication, and unit safety culture that facilitated applying safety science principles to clinical care. The MAOI decreased from 5.03% to 4.65% (absolute change -0.38% [95% CI, -0.88% to 0.12%]). Statistically significant decreases in indicators for obstetric trauma without instruments and primary cesarean delivery were observed. A statistically significant increase in neonatal birth trauma was observed, but the overall rate of unexpected newborn complications was unchanged.

CONCLUSIONS

The SPPC had a favorable impact on unit patient safety culture and processes, but short-term impact on maternal and neonatal adverse events was mixed.

Training and assessment of non-technical skills in Norwegian helicopter emergency services: a cross-sectional and longitudinal study

Background

Deficient non-technical skills (NTS) among providers of critical care in helicopter emergency medical services (HEMS) is a threat to patient and operational safety. Skills can be improved through simulation-based training and assessment. A previous study indicated that physicians underwent less frequent training compared to pilots and HEMS crew members (HCM) and that all professional groups in Norwegian HEMS received limited training in how to cope with fatigue. Since then, training initiatives and a fatigue risk management project has been initiated. Our study aimed to explore if the frequency of simulation-based training and assessment of NTS in Norwegian HEMS has changed since 2011 following these measures.

Methods

A cross-sectional web-based survey from October through December 2016, of physicians, HCM and pilots from all civilian Norwegian HEMS-bases reporting the overall extent of simulation-based training and assessment of NTS.

Results

Of 214 invited, 109 responses were eligible for analysis. The frequency of simulation-based training and assessment of NTS has increased significantly for all professional groups in Norwegian HEMS, most prominently for the physicians. For all groups, the frequency of assessment is generally lower than the frequency of training.

Conclusions

Physicians in Norwegian HEMS seem to have adjusted to the NTS training culture of the other crew member groups. This might be a consequence of improved NTS training programs. The use of behavioural marker systems systematically in HEMS should be emphasized.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0583-1) contains supplementary material, which is available to authorized users.

Examining interprofessional team interventions designed to improve nursing and team outcomes in practice: a descriptive and methodological review

Effective interprofessional (IP) team-based care is critical to enhance the delivery of efficient care and improve nursing and IP team outcomes. This study aims to review the most recent IP team intervention studies that focused on outcomes related to nursing and IP teams. PubMed, CINAHL, PsycINFO, and Embase were searched for existing literature published between January 2011 and December 2016. The search strategy was developed through both literature review and consultation with a health sciences librarian. This review included IP team intervention studies published in peer-reviewed journals and written in English. Studies were included if they conducted an IP team intervention for healthcare teams that include nurses and examined outcomes related to nursing and the IP teams. Based on inclusion and exclusion criteria, 41 articles were included for the final review. Two authors extracted data on the characteristics of IP team interventions, assessment methods, and their outcomes related to nursing and IP teams using a data abstraction tool developed by the research team. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. We found that most of the included studies were conducted in the US and on inpatient units. A quasi-experimental study design was most commonly employed. Most studies conducted IP team training such as TeamSTEPPS® as a one-time activity. The most common outcomes measured were attitudes or perceptions about IP teamwork or communication, followed by patient-related outcomes, and knowledge or skills about IP competencies. The quality of the included studies was generally low. The findings from this review will contribute to understanding the characteristics of current IP intervention studies and call for IP scholars to design more rigorous yet realistic IP intervention studies.

Patient safety initiatives in obstetrics: a rapid review

OBJECTIVES

This review was commissioned by WHO, South Africa-Country office because of an exponential increase in medical litigation claims related to patient safety in obstetrical care in the country. A rapid review was conducted to examine the effectiveness of quality improvement (QI) strategies on maternal and newborn patient safety outcomes, risk of litigation and burden of associated costs.

DESIGN

A rapid review of the literature was conducted to provide decision-makers with timely evidence. Medical and legal databases (eg, MEDLINE, Embase, LexisNexis Academic, etc) and reference lists of relevant studies were searched. Two reviewers independently performed study selection, abstracted data and appraised risk of bias. Results were summarised narratively.

INTERVENTIONS

We included randomised clinical trials (RCTs) of QI strategies targeting health systems (eg, team changes) and healthcare providers (eg, clinician education) to improve the safety of women and their newborns. Eligible studies were limited to trials published in English between 2004 and 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

RCTs reporting on patient safety outcomes (eg, stillbirths, mortality and caesarean sections), litigation claims and associated costs were included.

RESULTS

The search yielded 4793 citations, of which 10 RCTs met our eligibility criteria and provided information on over 500 000 participants. The results are presented by QI strategy, which varied from one study to another. Studies including provider education alone (one RCT), provider education in combination with audit and feedback (two RCTs) or clinician reminders (one RCT), as well as provider education with patient education and audit and feedback (one RCT), reported some improvements to patient safety outcomes. None of the studies reported on litigation claims or the associated costs.

CONCLUSIONS

Our results suggest that provider education and other QI strategy combinations targeting healthcare providers may improve the safety of women and their newborns during childbirth.

Interprofessional education involving didactic TeamSTEPPS® and interactive healthcare simulation: A systematic review

The didactic portion of TeamSTEPPS®, which focuses on teaching teamwork and communication, coupled with interactive simulation methods provides a unique interprofessional education (IPE) learning environment. Across the literature there are a wide variety of such programs described, but there is not a consensus on the most effective methodology. A systematic review was therefore undertaken to synthesize, critically appraise, and evaluate existing literature on IPE programs that utilize didactic TeamSTEPPS in conjunction with interactive healthcare simulation. EBSCO and PubMed databases were searched from inception through March 2017 using predetermined inclusion and exclusion criteria. The initial search yielded 66 articles which was reduced to 42 peer-reviewed publications after duplicates were removed. An additional 2 articles were identified via hand search. Therefore, 44 articles were identified and reviewed and 11 studies met all inclusion criteria. Critical appraisal was performed using The Medical Education Research Study Quality Instrument and Newcastle-Ottawa Scale-Education instruments. The outcome measures associated with each program as well as specifics of the didactic portion and interactive healthcare simulation are further explored in this review. It is anticipated that the findings from this systematic review will aid in the development of future evidence-based interprofessional programs.

Interdisciplinary Crisis Resource Management Training: How Do Otolaryngology Residents Compare? A Survey Study

Objective

Emergent medical crises, such as acute airway obstruction, are often managed by interdisciplinary teams. However, resident training in crisis resource management traditionally occurs in silos. Our objective was to compare the current state of interdisciplinary crisis resource management (IDCRM) training of otolaryngology residents with other disciplines.

Methods

A survey study examining (1) the frequency with which residents are involved in interdisciplinary crises, (2) the current state of interdisciplinary training, and (3) the desired training was conducted targeting Canadian residents in the following disciplines: otolaryngology, anesthesiology, emergency medicine, general surgery, obstetrics and gynecology, internal medicine, pediatric emergency medicine, and pediatric/neonatal intensive care.

Results

A total of 474 surveys were completed (response rate, 12%). On average, residents were involved in 13 interdisciplinary crises per year. Only 8% of otolaryngology residents had access to IDCRM training, as opposed to 66% of anesthesiology residents. Otolaryngology residents reported receiving an average of 0.3 hours per year of interdisciplinary training, as compared with 5.4 hours per year for pediatric emergency medicine residents. Ninety-six percent of residents desired more IDCRM training, with 95% reporting a preference for simulation-based training.

Discussion

Residents reported participating in crises managed by interdisciplinary teams. There is strong interest in IDCRM and crisis resource management training; however, it is not uniformly available across Canadian residency programs. Despite their pivotal role in managing critical emergencies such as acute airway obstruction, otolaryngology residents received the least training.

Implication

IDCRM should be explicitly taught since it reflects reality and may positively affect patient outcomes.

Training future anesthesiologists in obstetric care

PURPOSE OF REVIEW

In order for the obstetric anesthesiologist to become a true perioperative / peripartum physician, a change in formative programs and certification process in anesthesia are needed.

RECENT FINDINGS

Anesthesia training programs are migrating to competency based medical education (CBME) worldwide. The traditional model of attending lectures, grand rounds, reading textbooks and journal papers should be complemented by virtual modalities such as massive open online courses or online teaching tools. The gold standard for assessment of procedural skills in anesthesia consists of a combination of global rating scales and previously validated checklists. Behaviors in the perioperative environment not directly related to the use of drugs, equipment or medical expertise are known as anesthesiologist nontechnical skills and trainees must learn and practice these skills; nontechnical skills can determine 50-80% of adverse events in high-risk professions, including medicine. Regular certification programs are also an important component of the new approach in medical education, in some high-income countries, the specialist anesthesiologist is undertaking regular certification but the impact of these programs on overall outcomes is still unknown.

SUMMARY

The obstetric population is becoming a higher risk population, requiring an obstetric anesthesiologist taking on the role of a perioperative / peripartum physician. It is essential that anesthesia training programs migrate to CBME through simulation-based curriculum that allow the achievement of nontechnical skills and team work competencies. It is also essential that regular certification for specialist anesthesiologists occur throughout their entire career.

Simulation-based Education to Ensure Provider Competency Within the Health Care System

The acquisition and maintenance of individual competency is a critical component of effective emergency care systems. This article summarizes consensus working group deliberations and recommendations focusing on the topic "Simulation-based education to ensure provider competency within the healthcare system." The authors presented this work for discussion and feedback at the 2017 Academic Emergency Medicine Consensus Conference on "Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes," held on May 16, 2017, in Orlando, Florida. Although simulation-based training is a quality and safety imperative in other high-reliability professions such as aviation, nuclear power, and the military, health care professions still lag behind in applying simulation more broadly. This is likely a result of a number of factors, including cost, assessment challenges, and resistance to change. This consensus subgroup focused on identifying current gaps in knowledge and process related to the use of simulation for developing, enhancing, and maintaining individual provider competency. The resulting product is a research agenda informed by expert consensus and literature review.

The utility of bedside simulation for training in critical care obstetrics

Over the last 2 decades, the maternal mortality ratio in the United States has doubled from 7.4/100,000 live births in 1986 to 14.5/100,000 today. Despite great advances in health care, increasing rates of maternal morbidity and mortality in the United States have prompted calls to action to reverse this disturbing trend. Assisted reproductive technology has allowed women to delay childbearing to more advanced ages, resulting in a greater number of pregnancies complicated by one or more of the diseases associated with aging, such as cardiovascular disease, cancer, type 2 diabetes, and hypertension. The obesity epidemic, increasing rates of chronic diseases affecting pregnancy, steadily rising cesarean delivery rate with resulting complications, and medical advances allowing women with rare, but serious diseases to conceive contribute to rising maternal morbidity and mortality rates. Obstetric critical care simulation training may result in improved multidisciplinary teamwork and patient outcomes; and fewer medical and communication errors.

Medical Aesthetics Training: Shifting to Collective Competence

With increased demands for medical aesthetics procedures and the sudden profusion of newly licensed, and unlicensed, providers who are performing these medical aesthetics procedures also comes the responsibility to shift to collective competence. Collective competence refers to what occurs among professionals in action, emphasizing the sharing of experiences, knowledge, and perceptions among those who are providing services to the medical aesthetics client. Registered nurses and medical students are not taught to perform cosmetic procedures in basic nursing or medical programs and thus require a post-entry-level education to validate their competency. The current medical aesthetics apprenticeship training approach of see one, do one, and teach one focuses on teaching technical skills and thus does not sufficiently address the ever-changing health care context and the ambiguity in practitioner role. Recent scholars highlight that when health care failed or an error has been identified, it is rarely adduced to an individual's competence but rather is more likely to be a failure of the collective team. In this article, we are advocating for a change in how medical aesthetics practitioners are trained. In particular, it advocates creating opportunities within the curricula to train practitioners as a collective body, as opposed to providing training that focuses on the individual's competence and technical skills alone.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Simulation Using TeamSTEPPS to Promote Interprofessional Education and Collaborative Practice

Effective interprofessional collaborative practice is critical to maximizing patient safety and providing quality patient care; incorporating these strategies into the curriculum is an important step toward implementation. This study assessed whether TeamSTEPPS training using simulation could improve student knowledge of TeamSTEPPS principles, self-efficacy toward interprofessional collaborative practice, and team performance. Students (N = 201) demonstrated significant improvement in all of the targeted measurements.

A Proficiency Based Stepwise Endovascular Curricular Training (PROSPECT) Program Enhances Operative Performance in Real Life: A Randomised Controlled Trial

OBJECTIVES

Healthcare evolution requires optimisation of surgical training to provide safe patient care. Operating room performance after completion of proficiency based training in vascular surgery has not been investigated.

DESIGN

A randomised controlled trial evaluated the impact of a Proficiency based Stepwise Endovascular Curricular Training program (PROSPECT) on the acquisition of endovascular skills and the transferability of these skills to real life interventions.

MATERIALS

All subjects performed two endovascular interventions treating patients with symptomatic iliac and/or superficial femoral artery stenosis under supervision. Primary outcomes were technical performances (Global Rating Scale [GRS]; Examiner Checklist), operative metrics, and patient outcomes, adjusted for case difficulty and trainee experience. Secondary outcomes included knowledge and technical performance after 6 weeks and 3 months.

METHODS

Thirty-two general surgical trainees were randomised into three groups. Besides traditional training, the first group (n = 11) received e-learning and simulation training (PROSPECT), the second group (n = 10) only had access to e-learning, while controls (n = 11) did not receive supplementary training.

RESULTS

Twenty-nine trainees (3 dropouts) performed 58 procedures. Trainees who completed PROSPECT showed superior technical performance (GRS 39.36 ± 2.05; Checklist 63.51 ± 3.18) in real life with significantly fewer supervisor takeovers compared with trainees receiving e-learning alone (GRS 28.42 ± 2.15; p = .001; Checklist 53.63 ± 3.34; p = .027) or traditional education (GRS 23.09 ± 2.18; p = .001; Checklist 38.72 ± 3.38; p = .001). Supervisors felt more confident in allowing PROSPECT trained physicians to perform basic (p = .006) and complex (p = .003) procedures. No differences were detected in procedural parameters (such as fluoroscopy time, DAP, procedure time, etc.) or complications. Proficiency levels were maintained up to 3 months.

CONCLUSIONS

A structured, stepwise, proficiency based endovascular curriculum including e-learning and simulation based training should be integrated early into training programs to enhance trainee performance.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Crisis Team Management in a Scarce Resource Setting: Angkor Hospital for Children in Siem Reap, Cambodia

INTRODUCTION

A crisis team management (CTM) simulation course was developed by volunteers from Health Volunteers Overseas for physicians and nurses at Angkor Hospital for Children (AHC) in Siem Reap, Cambodia. The framework for the course was adapted from crisis resource management (1, 2), crisis team training (3), and TeamSTEPPs© models (4). The CTM course focused on teaching physicians and nurses on the development of team performance knowledge, skills, and attitudes. Challenges to providing this course at AHC included availability of simulation equipment, cultural differences in learning, and language barriers. The purpose of this project was to evaluate the impact of a CTM simulation course at AHC on attitudes and perceptions of participants on concepts related to team performance.

METHODS

Each of the CTM courses consisted of three lectures, including team performance concepts, communication, and debriefing followed by rotation through four simulation scenarios. The evaluation instrument used to evaluate the AHC CTM course was developed for Cambodian staff at AHC based on TeamSTEPPs© instruments evaluating attitude and perceptions of team performance (5). CTM team performance concepts included in lectures, debriefing sessions, and the evaluation instrument were: team structure, leadership, situation monitoring, mutual support, and communication. The Wilcoxon signed-rank test was used to analyze pre- and post-test paired data from participants in the course.

RESULTS

Of the 54 participants completing the three CTM courses at AHC, 27 were nurses, 6 were anesthetists, and 21 were physicians. Attitude and perception scores were found to significantly improve (p < 0.05) for team structure, leadership, situation monitoring, and communication. Team performance areas that improved the most were: discussion of team performance, communication, and exchange of information.

CONCLUSION

Teaching of non-technical skills can be effective in a setting with scarce resources in a Southeastern Asian country.

In Situ Operating Room-Based Simulation: A Review

OBJECTIVE

To systematically review the literature surrounding operating room-based in situ training in surgery.

METHODS

A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible.

RESULTS

The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics.

CONCLUSIONS

Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated.

[Safety culture in orthopedics and trauma surgery : Course concept: interpersonal competence by the German Society for Orthopaedics and Trauma (DGOU) and Lufthansa Aviation Training]

Patient safety has become a central and measurable key factor in the routine daily medical practice. The human factor plays a decisive role in safety culture and has moved into focus regarding the reduction of treatment errors and undesired critical incidents. Nonetheless, the systematic training in communication and interpersonal competences has so far only played a minor role. The German Society of Orthopaedics and Trauma (DGOU) in cooperation with the Lufthansa Aviation Training initiated a course system for interpersonal competence. Several studies confirmed the reduction of critical incidents and costs after implementation of a regular and targeted human factor training. The interpersonal competence should be an essential component of specialist training within the framework of a 3‑column model.

Effect of Nurse-Led Review Plus Simulation on Obstetric/Perinatal Nurses' Self-Assessed Knowledge and Confidence

Simulation may help both novice and experienced clinicians maintain competence in managing high-risk, low-frequency obstetric and perinatal complications and emergencies. Therefore, we designed a pre-/posttest study to determine whether a day of nurse-led lecture plus low-fidelity simulation would increase registered nurses' self-assessed knowledge and confidence in managing five high-risk obstetric/perinatal situations. The Nursing Management of OB/Perinatal Complications & Emergencies (NursOB) scale was distributed to 67 labor/birth and postpartum nurses before and after a simulation training day. Preliminary findings supported validity and reliability of the NursOB scale, but nurses' knowledge and confidence did not improve after the simulation (p < .05). Anecdotally, nurses' interest in competence reviews was reinvigorated, and we gained practical knowledge in simulation delivery. Future simulations could enhance outcome measures, improve drills, and establish criterion-related validity of the NursOB scale. More research is warranted.