standardisation of multidisciplinary obstetric emergency ... · the active components of effective...
TRANSCRIPT
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IMOET National MeetingTuesday 30th September 2014Dublin Castle
Standardisation of multidisciplinary obstetric emergency training nationally.
1
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Teamwork and Obstetric Emergencies
Dr Niamh Hayes
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• Aim: Get cash!
ATM Return:
Simple task…
• Cash return first?
• Card return first?
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• Aim: Get cash!
ATM Return: Cash return first:
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• Aim: Get cash!
ATM Return: Cash return first:
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• Aim: Get cash!
ATM Return: Card return first:
> 10,000 transactions p.a. leave cash behind
> €1,000,000 p.a.
… single bank R.O.I.
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• Aim: Get cash!
ATM Return: Card return first:
Simple cognitive error…
• Person capable of performing task safely
• Has done so many times in the past
• Faces significant personal consequences for error
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Complexity of medical crisis?
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▫ Context
▫ Definition
▫ Principles
▫ Metrics
▫ Resources
▫ Summary
Outline
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44,000 - 98,000 deaths p.a.
Context: Scope of the problem
IOM “To Err is Human” 1999
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600 - 1300 deaths p.a.
Context: Scope of the problem
IOM “To Err is Human” RoI?
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442 deaths 1999
Context: Scope of the problem
Commercial aviation fatalities worldwide 1999
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Causes?
technical competencies
procedural knowledge
psychomotor skills
non-technical competencies
cognitive skills
social skills
safe task completion
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• Non-technical failures
resource management
Causes?
cockpit
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• Non-technical failures
resource management
Causes?
crew
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• Non-technical failures
resource management
Causes?
crisis
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• Crisis resource management:
“The ability to translate medical knowledge to real
world actions in the setting of an emergency”
Definition
Howard SK et al. Anesthesia crisis resource management training : teaching anaesthesiologists to handle critical incidents. Aviation, space and environmental medicine 1992
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Principles of CRMEFFECTIVE
COMMUNICATION
MUTUAL RESPECT
SHARED DECISION MAKING
SITUATIONAL AWARENESS
USE ALL AVAILABLE RESOURCES
LEADERSHIP AND FOLLOWERSHIP
Adapted from: Rall and Gaba, Miller’s Anesthesia 7th Edition
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*
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*Teamwork elements from ACLS provider manual 2010, PROMPT provider manual
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Principles of CRMEFFECTIVE
COMMUNICATION
CLOSED-LOOP COMMUNICATION
Strategy of verification to make sure that the message sent was received and interpreted as intended
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Principles of CRMEFFECTIVE
COMMUNICATION
STRUCTURED COMMUNICATION
From HSE.ie and App Store (accessed 15th September 2014)
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National guideline for communication (handover) in maternity services in Ireland
Principles of CRM
295 pages!!!
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Principles of CRM
LEADERSHIP AND FOLLOWERSHIP
USE ALL AVAILABLE RESOURCES
• Clear role/task allocation• Know limitations and ask for help early• Mutual support/cross checking
• Objective evidence (point of care testing)• Human resources• Cognitive aids (algorithms)
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Principles of CRM
SITUATIONAL AWARENESS
What?
So what?
What now?
Information gathering?
Understanding?
Anticipation?
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Principles of CRM
MUTUAL RESPECT
SHARED DECISION MAKING
• “Power distance” (hierarchy)• Treat input from other team members
legitimately
• “hint and hope”…• SBAR?• Critical language: CUS
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Principles of CRMEFFECTIVE
COMMUNICATION
MUTUAL RESPECT
SHARED DECISION MAKING
SITUATIONAL AWARENESS
USE ALL AVAILABLE RESOURCES
LEADERSHIP AND FOLLOWERSHIP
Adapted from: Rall and Gaba, Miller’s Anesthesia 7th Edition
*Teamwork elements from ACLS provider manual 2010, PROMPT provider manual
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• Domain/context-specific training interventions
• Good face validity…
• Evidence for construct validity (translational science)?
Metrics
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Metrics: Evidence for success?
Siassakos D et al. The active components of effective training in obstetric emergencies. BJOG 2009;116:1028-32
Southmead Hospital, Bristol (UK)
• Infrastructural changes (protocols, props…)
• Regular in-house drills for all staff
• 51% reduction in Apgar5 <7• 50% reduction in HIE• 75% reduction in Erb’s palsy after shoulder
dystocia• 40% reduction in median DDI for cord prolapse
Draycott T et al. Does trianing in obstetric emergencies improve neonatal outcome? BJOG 2006;113:177-82
Draycott T et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008;112:14-20
Siassakos D et al. Retrospective cohort study of DDI with umbilical cord prolapse: the effect of team training. BJOG 2009;116:1089-96
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Metrics: Evidence for success?
Siassakos D et al. The active components of effective training in obstetric emergencies. BJOG 2009;116:1028-32
BDIMC, Boston (US)
• Teamwork course for all staff
• Debriefings, improved handover
• Protocol development
• Selected clinical drills
• 23% reduction in adverse obs events• 62% reduction in malpractice claims• Labour staff > positive attitude to safety
Pratt S. Impact of CRM-based team training on obstetric outcomes and clinicians’ safety attitudes. Jt Comm J Qual Patient Saf 2007;33:720-5
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Metrics: Evidence for success?
Siassakos D et al. The active components of effective training in obstetric emergencies. BJOG 2009;116:1028-32
Liverpool Women’s Hospital (UK)
• Integrated risk management
• Patient involvement
• Regular team briefings and drills
• Infrastructural improvements
• 11% reduction in AE with suboptimal care• 50% reduction in Apgar5 <4• 50% reduction in cord pH <7• 86% reduction in Erb’s palsy
Scholefield H. Embedding quality improvement and patient safety at Liverpool Women’s NHS Foundation Trust. Best Pract Res Clin Obstet Gynecol 2007;21:593-607
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Metrics: Evidence for success?
Siassakos D et al. The active components of effective training in obstetric emergencies. BJOG 2009;116:1028-32
Rigshospitalet, Copenhagen (DK)
• Clinical drills
• Streamlined protocols
• Eclampsia and haemorrhage boxes
• Improved staff confidence scores & 45% reduction in midwifery staff sick leave
Sorensen JL. The implementation and evaluation of a mandatory multi-professional obstetric skills training program. Acta Obstet Gynecol Scand. 2009;88(10):1107-17
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Metrics: Evidence for success?
Evidence = association (not causation)
Institution-level incentives to training and safety
culture
Non-threatening training and assessment for entire
workforce
Self-directed infrastructural changes (local solutions)
Relevant, in-house training
Realistic training tools (high fidelity)
Multiprofessional clinical and teamwork training
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Resources?
Guideline Personnell Other Metrics
O & G Ireland Obstetric Manikins Face validity satisfaction scores
COMPASS training manual (HSE)
Midwifery Birthing Simulator Others?
NEWS guideline (appendix 6, HSE)
Anaesthesia Resus Manikin Unit dependent?
ISBAR app (iTunes & android)
+++
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Practical skills & drills elements
EFFECTIVE COMMUNICATION
MUTUAL RESPECT
SHARED DECISION MAKING
SITUATIONAL AWARENESS
USE ALL AVAILABLE RESOURCES
LEADERSHIP AND FOLLOWERSHIP
TTT elements
Elements for certain
scenarios
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• If you do only one thing when you return to your unit,
use ISBAR
Looking forward