Key components influencing the sustainability of a multi-professional obstetric emergencies training programme in a middle-income setting: a qualitative study.

BACKGROUND: Multi-professional obstetric emergencies training is one promising strategy to improve maternity care. Sustaining training programmes following successful implementation remains a challenge. Understanding, and incorporating, key components within the implementation process can embed interventions within healthcare systems, thereby enhancing sustainability. This study aimed to identify key components influencing sustainability of PRactical Obstetric Multi-Professional Training (PROMPT) in the Philippines, a middle-income setting. METHODS: Three hospitals were purposively sampled to represent private, public and teaching hospital settings. Two focus groups, one comprising local trainers and one comprising training participants, were conducted in each hospital using a semi-structured topic guide. Focus groups were audio recorded. Data were analysed using thematic analysis. Three researchers independently coded transcripts to ensure interpretation consistency. RESULTS: Three themes influencing sustainability were identified; attributes of local champions, multi-level organisational involvement and addressing organisational challenges. CONCLUSIONS: These themes, including potential barriers to sustainability, should be considered when designing and implementing training programmes in middle-income settings. When 'scaling-up', local clinicians should be actively involved in selecting influential implementation champions to identify challenges and strategies specific to their organisation. Network meetings could enable shared learning and sustain enthusiasm amongst local training teams. Policy makers should be engaged early, to support funding and align training with national priorities.

Skills training for operative vaginal birth.

Skilled, safe operative vaginal birth can substantially improve maternal and neonatal outcomes arising from complications in the second stage of labour and should be available in a diverse range of maternity settings for women across the world. Operative vaginal births are complex, requiring a combination of good technical skills, non-technical skills as well as sensitivity from the accoucher. It is axiomatic that accouchers should be adequately trained and simulation-based training is a promising strategy to improve outcomes and increase the rates of operative vaginal birth. However, not all training is effective and although there are likely to be important lessons from other areas of simulation-based obstetric emergencies training that are generalisable, more research is required to identify effective training interventions for operative vaginal birth. Training for operative vaginal birth should also be operationalised for maximum spread and benefit.

A rapid cycle method for local adaptation of an obstetric emergencies training program.

OBJECTIVE: To describe the adaptation of an obstetric emergencies training program to align with local clinical practice. METHODS: A feasibility study was conducted to investigate the potential implementation of the PRactical Obstetric Multi-Professional Training (PROMPT) program at eight urban tertiary hospitals in the Philippines. Multi-professional teams attended a 2-day course on September 23 and 24, 2015, that comprised a demonstration PROMPT course (day 1) and a Train-the-Trainers session (day 2). During a facilitated adaptation session, each team reviewed the PROMPT algorithms for eclampsia, severe pre-eclampsia, postpartum hemorrhage and sepsis. The teams marked steps concordant with local practice and identified differences with local practice. Suggested amendments were reviewed by the PROMPT project team, using clinical guidelines to support any adaptations. RESULTS: The PROMPT algorithm for initial management of eclampsia was used as an exemplar. Five of the nine management steps were concordant with local practice: support; airway; breathing; circulation; and control seizures. Amendments were successfully implemented for the following steps: call for help; magnesium sulfate loading dose; and magnesium sulfate maintenance dose. CONCLUSION: Rapid and efficient adaptation of PROMPT training materials for use in the Philippines was possible using a facilitated and focused approach, utilizing the expertise of a representative mix of local healthcare professionals and evidence-based guidelines.

The cost of local, multi-professional obstetric emergencies training.

INTRODUCTION: We aim to outline the annual cost of setting up and running a standard, local, multi-professional obstetric emergencies training course, PROMPT (PRactical Obstetric Multi-Professional Training), at Southmead Hospital, Bristol, UK - a unit caring for approximately 6500 births per year. MATERIAL AND METHODS: A retrospective, micro-costing analysis was performed. Start-up costs included purchasing training mannequins and teaching props, printing of training materials and assembly of emergency boxes (real and training). The variable costs included administration time, room hire, additional printing and the cost of releasing all maternity staff in the unit, either as attendees or trainers. Potential, extra start-up costs for maternity units without established training were also included. RESULTS: The start-up costs were €5574 and the variable costs for 1 year were €143 232. The total cost of establishing and running training at Southmead for 1 year was €148 806. Releasing staff as attendees or trainers accounted for 89% of the total first year costs, and 92% of the variable costs. The cost of running training in a maternity unit with around 6500 births per year was approximately €23 000 per 1000 births for the first year and around €22 000 per 1000 births in subsequent years. CONCLUSIONS: The cost of local, multi-professional obstetric emergencies training is not cheap, with staff costs potentially representing over 90% of the total expenditure. It is therefore vital that organizations consider the clinical effectiveness of local training packages before implementing them, to ensure the optimal allocation of finite healthcare budgets.

Laparoscopic simulation training in gynaecology: Current provision and staff attitudes - a cross-sectional survey.

The objectives of this study were to explore current provision of laparoscopic simulation training, and to determine attitudes of trainers and trainees to the role of simulators in surgical training across the UK. An anonymous cross-sectional survey with cluster sampling was developed and circulated. All Royal College of Obstetricians and Gynaecologists (RCOG) Training Programme Directors (TPD), College Tutors (RCT) and Trainee representatives (TR) across the UK were invited to participate. One hundred and ninety-six obstetricians and gynaecologists participated. Sixty-three percent of hospitals had at least one box trainer, and 14.6% had least one virtual-reality simulator. Only 9.3% and 3.6% stated that trainees used a structured curriculum on box and virtual-reality simulators, respectively. Respondents working in a Large/Teaching hospital (p = 0.008) were more likely to agree that simulators enhance surgical training. Eighty-nine percent agreed that simulators improve the quality of training, and should be mandatory or desirable for junior trainees. Consultants (p = 0.003) and respondents over 40 years (p = 0.011) were more likely to hold that a simulation test should be undertaken before live operation. Our data demonstrated, therefore, that availability of laparoscopic simulators is inconsistent, with limited use of mandatory structured curricula. In contrast, both trainers and trainees recognise a need for greater use of laparoscopic simulation for surgical training.

Myths and realities of training in obstetric emergencies.

Training for intrapartum emergencies is a promising strategy to reduce preventable harm during birth; however, not all training is clinically effective. Many myths have developed around such training. These principally derive from misinformed beliefs that all training must be effective, cheap, independent of context and sustainable. The current evidence base for effective training supports local, unit-based and multi-professional training, with appropriate mannequins, and practice-based tools to support the best care. Training programmes based on these principles are associated with improved clinical outcomes, but we need to understand how and why that is, and also why some training is associated with no improvements, or even deterioration in outcomes. Effective training is not cheap, but it can be cost-effective. Insurers have the fiscal power to incentivise training, but they should demand the evidence of clinical effect; aspiration and proxies alone should no longer be sufficient for funding, in any resource setting.

Curriculum development for basic gynaecological laparoscopy with comparison of expert trainee opinions; prospective cross-sectional observational study.

OBJECTIVE: To develop content for a basic laparoscopic curriculum in gynaecology. STUDY DESIGN: Prospective cross-sectional observational study. Modified Delphi method with three iterations undertaken by an invited group of national experts across the United Kingdom (UK). Two anonymous online surveys and a final physical group meeting were undertaken. Junior trainees in gynaecology undertook a parallel iteration of the Delphi process for external validation. Population included: expert panel - certified specialists in minimal-access gynaecological surgery, RCOG national senior trainee representatives, and medical educationalists, junior trainees group - regional trainees in gynaecology in first and second year of speciality training. RESULTS: Experts (n=37) reached fair to almost complete significant agreement (κ=0.100-0.8159; p<0.05) on eight out of nine questions by the second iteration. Trainees (n=19) agreed with the experts on 89% (51/57) of categories to be included in the curriculum. Findings indicated that 39 categories should be included in the curriculum. Port placement, laparoscopic equipment and patient selection were ranked the most important theoretical categories. Hand-eye co-ordination, camera navigation and entry techniques were deemed the most valuable skills. Diagnostic laparoscopy, laparoscopic sterilisation, and laparoscopic salpingectomy were the operations agreed to be most important for inclusion. Simulation training was agreed as the method of skill development. The expert panel favoured box trainers, whereas the junior trainee group preferred virtual reality simulators. A basic simulation laparoscopic hand-eye co-ordination test was proposed as a final assessment of competence in the curriculum. CONCLUSION: Consensus was achieved on the content of a basic laparoscopic curriculum in gynaecology, in a cost- and time-effective, scientific process. The Delphi method provided a simple, structured consumer approach to curriculum development that combined views of trainers and trainees that could be used to develop curricula in other areas of post-graduate education.

Using data and quality monitoring to enhance maternity outcomes: a qualitative study of risk managers' perspectives.

INTRODUCTION: Risk management is a core part of healthcare practice, especially within maternity services, where litigation and societal costs are high. There has been little investigation into the experiences and opinions of those staff directly involved in risk management: lead obstetricians and specialist risk midwives, who are ideally placed to identify how current implementation of risk management strategies can be improved. METHODS: A qualitative study of consultant-led maternity units in an English region. Semistructured interviews were conducted with the obstetric and midwifery risk management leads for each unit. We explored their approach to risk management, particularly their opinions regarding quality monitoring and related barriers/issues. Interviews were recorded, transcribed and thematically analysed. RESULTS: Twenty-seven staff from 12/15 maternity units participated. Key issues identified included: concern for the accuracy and validity of their local data, potential difficulties related to data collation, the negative impact of external interference by national regulatory bodies on local clinical priorities, the influence of the local culture of the maternity unit on levels of engagement in the risk management process, and scepticism about the value of benchmarking of maternity units without adjustment for population characteristics. CONCLUSIONS: Local maternity risk managers may provide valuable, clinically relevant insights into current issues in clinical data monitoring. Improvements should focus on the accuracy and ease of data collation with a need for an agreed maternity indicators set, populated from validated databases, and not reliant on data collection systems that distract clinicians from patient activity and quality improvement. It is clear that working relationships between risk managers, their own clinical teams and external national bodies require improvement and alignment. Further discussion regarding benchmarking between maternity units is required prior to implementation. These findings are likely to be relevant to other clinical specialties.

What makes maternity teams effective and safe? Lessons from a series of research on teamwork, leadership and team training.

We describe lessons for safety from a synthesis of seven studies of teamwork, leadership and team training across a healthcare region. Two studies identified successes and challenges in a unit with embedded team training: a staff survey demonstrated a positive culture but a perceived need for greater senior presence; training improved actual emergency care, but wide variation in team performance remained. Analysis of multicenter simulation records showed that variation in patient safety and team efficiency correlated with their teamwork but not individual knowledge, skills or attitudes. Safe teams tended to declare the emergency earlier, hand over in a more structured way, and use closed-loop communication. Focused and directed communication was also associated with better patient-actor perception of care. Focus groups corroborated these findings, proposed that the capability and experience of the leader is more important than seniority, and identified teamwork and leadership issues that require further research.

Implementation of laparoscopic virtual-reality simulation training in gynaecology: a mixed-methods design.

OBJECTIVES: Virtual-reality (VR) training has been demonstrated to improve laparoscopic surgical skills in the operating theatre. The incorporation of laparoscopic VR simulation into surgical training in gynaecology remains a significant educational challenge. We undertook a pilot study to assess the feasibility of the implementation of a laparoscopic VR simulation programme into a single unit. STUDY DESIGN: An observational study with qualitative analysis of semi-structured group interviews. Trainees in gynaecology (n=9) were scheduled to undertake a pre-validated structured training programme on a laparoscopic VR simulator (LapSim(®)) over six months. The main outcome measure was the trainees' progress through the training modules in six months. Trainees' perceptions of the feasibility and barriers to the implementation of laparoscopic VR training were assessed in focus groups after training. RESULTS: Sixty-six percent of participants completed six of ten modules. Overall, feedback from the focus groups was positive; trainees felt training improved their dexterity, hand-eye co-ordination and confidence in theatre. Negative aspects included lack of haptic feedback, and facility for laparoscopic port placement training. Time restriction emerged as the main barrier to training. CONCLUSIONS: Despite positive perceptions of training, no trainee completed more than two-thirds of the modules of a self-directed laparoscopic VR training programme. Suggested improvements to the integration of future laparoscopic VR training include an additional theoretical component with a fuller understanding of benefits of VR training, and scheduled supervision. Ultimately, the success of a laparoscopic VR simulation training programme might only be improved if it is a mandatory component of the curriculum, together with dedicated time for training. Future multi-centred implementation studies of validated laparoscopic VR curricula are required.

Development of maternity dashboards across a UK health region; current practice, continuing problems.

OBJECTIVE: To assess the development of local clinical dashboards in line with UK national guidance and to identify ongoing issues being faced by maternity units, across an entire health region, in developing quality assurance systems. STUDY DESIGN: A mixed-methods study involving all consultant-led maternity units in the South West of England Strategic Health Authority region (SWSHA). An electronic survey, followed by semi-structured interviews with the lead obstetrician and risk management midwife (or equivalent) of each maternity unit, to investigate methods employed to monitor outcomes locally, particularly the development of tools including maternity dashboards. Interviews were audio recorded, transcribed and thematically analysed to identify conceptual categories and themes. RESULTS: 12/15 eligible consultant-led maternity units participated in the study and 10/12 (83%) of these used a dashboard. There was an excessive number of non-standard indicators used by the maternity units, with 352 different quality indicators (QIs), covering 37 different indicator categories, with up to 39 different definitions for one particular QI. Issues identified were: an excess of indicators, disproportionate time taken to produce the dashboard, uncertainty surrounding thresholds for alert within the dashboards and a desire for more guidance and standardisation of indicators, and their use. CONCLUSIONS: Following recommendation by the Royal College of Obstetricians and Gynaecologists, maternity dashboards have been widely adopted by maternity units across the SWSHA to provide a local quality assurance system. There is, however, wide variation in both the quality indicators monitored and their definition. There is an urgent requirement for a national and international core set of maternity QIs. Further guidance is also required to inform alert thresholds for adverse outcomes. These perinatal data are collected electronically, and automating the production of a standardised dashboard is both possible and desirable.

Retention of factual knowledge after practical training for intrapartum emergencies.

OBJECTIVE: To determine knowledge retention 1 year after training for intrapartum emergencies. METHODS: Training was undertaken in 6 hospitals and the Bristol Medical Simulation Centre, UK, between November 2004 and March 2005. Participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were randomly recruited from participating hospitals and underwent practical training at their local hospital or simulation center with or without additional teamwork training. The primary outcome was change in factual knowledge over time, as assessed by a 185-question multiple-choice questionnaire before and after training. RESULTS: Mean scores at 6 (97.6 ± 23.0; n = 107) and 12 (98.2 ± 21.6; n = 98) months remained higher than those before training (79.6 ± 21.9, n = 140; both P < 0.001), but were slightly lower than those immediately after training (101.0 ± 21.3, n = 133; P < 0.001 and P = 0.007, respectively). The type of training had no effect on retention of knowledge. CONCLUSION: Training was associated with sustained retention of factual knowledge of obstetric emergencies care for at least 1 year. The decay in knowledge was small compared with the original gain in knowledge. Neither training location nor inclusion of teamwork training affected knowledge retention. Annual training seemed to be satisfactory for all staff groups.

Intrapartum care quality indicators: a systematic approach for achieving consensus.

OBJECTIVE: To identify published maternity intrapartum quality indicators and rationalise them to a core set. STUDY DESIGN: Prospective qualitative consensus group exercise. A literature search identified sets of intrapartum quality indicators in the English language. These were rationalised to a shortlist using criteria adapted from 'The Good Clinical Indicator Guide'. An expert panel from key UK professions and organisations utilised a modified Delphi process to devise a final agreed set of intrapartum quality indicators that are specific, measurable, modifiable and relevant to clinical practice. Each indicator was rated in two rounds of web-based surveys, followed by a final face-to-face meeting of the panel. RESULTS: 290 clinical indicators were identified within 96 clinical categories with up to 18 different definitions. After rationalisation, 10 core and 24 additional quality indicators entered the Delphi process. A final panel of 12 indicators was defined. CONCLUSIONS: By using a simple Delphi process we have defined a set of broad clinical quality indicators that provide a comprehensive coverage of labour and delivery outcomes. We believe that this pragmatic portfolio will be useful for many wishing to develop performance monitoring and maternity dashboard systems.

Validation of virtual reality simulation for obstetric ultrasonography: a prospective cross-sectional study.

INTRODUCTION: Ultrasonography is an important skill for obstetricians and gynecologists; however, trainees have highlighted ultrasonography as an area of deficiency in their training. We undertook a prospective cross-sectional comparative study to assess content and construct validity of an ultrasound virtual reality (VR) simulator (UltraSim). METHODS: Twenty-six physicians and sonographers of varied ultrasonography experience were recruited and divided into trainees (no formal ultrasonography training) and expert (certified) categories. They performed a VR simulation crown-rump length (CRL) ultrasound scan and growth ultrasound scan measuring biparietal diameter, occipitofrontal diameter, abdominal anteroposterior and transverse diameters, and femur length. Maximum pool depth (MPD), placental site, and fetal presentation were also assessed. Outcome measures included the mean absolute deviation and the variance of the absolute deviation from true measurements. Accuracy of determining placental site, fetal presentation, and MPD was assessed. The time taken to perform each type of scan was recorded. RESULTS: Trainees had significantly greater variation of measurement of CRL (P = 0.025) than the expert group. For late-pregnancy fetal biometry, the absolute deviation and the degree of variability for all measurements differed. These differences were statistically significant (P < 0.05) for all measurements except abdominal diameters and MPD. Trainees took significantly longer time to obtain CRL and fetal biometric scans (P < 0.001). All subjects correctly identified fetal presentation and placental site. CONCLUSIONS: Clinicians with differing ultrasonography expertise showed differing skill with the UltraSim VR simulator, demonstrating construct validity for skills needed in simulation. Consideration should be given to investigating whether trainees with minimal scanning experience can improve their clinical skills and efficiency with VR simulation.

Teamwork for clinical emergencies: interprofessional focus group analysis and triangulation with simulation.

Our purpose was to investigate health care professionals' beliefs about effective teamwork in medical emergencies based on their experiences. We used framework analysis of interprofessional focus groups in four secondary and tertiary maternity units. The participants were randomly selected senior and junior doctors, senior and junior midwives, and health care assistants, in five groups of 5 to 7 participants each. We found that optimal teamwork was perceived to be dependent on good leadership and availability of experienced staff. The participants described a good leader as one who verbally declares being the leader, communicates clear objectives, and allocates critical tasks, including communication with patients or their family, to suitable individual members. We triangulated the results with evidence from simulation to identify convergent findings and issues requiring further research. The findings will inform the development of teaching programs for medical teams who manage emergencies to improve patient safety and experience.

Evaluating the impact of simulation on translational patient outcomes.

INTRODUCTION: A long and rich research legacy shows that under the right conditions, simulation-based medical education (SBME) is a powerful intervention to increase medical learner competence. SBME translational science demonstrates that results achieved in the educational laboratory (T1) transfer to improved downstream patient care practices (T2) and improved patient and public health (T3). METHOD: This is a qualitative synthesis of SBME translational science research (TSR) that employs a critical review approach to literature aggregation. RESULTS: Evidence from SBME and health services research programs that are thematic, sustained, and cumulative shows that measured outcomes can be achieved at T1, T2, and T3 levels. There is also evidence that SBME TSR can yield a favorable return on financial investment and contributes to long-term retention of acquired clinical skills. The review identifies best practices in SBME TSR, presents challenges and critical gaps in the field, and sets forth a TSR agenda for SBME. CONCLUSIONS: Rigorous SBME TSR can contribute to better patient care and improved patient safety. Consensus conference outcomes and recommendations should be presented and used judiciously.

Team communication with patient actors: findings from a multisite simulation study.

INTRODUCTION: Patient satisfaction is an important healthcare outcome and communication with clinical staff is an important determinant. Simulation could identify problems and inform corrective action to improve patient experience. METHODS: One hundred eight randomly selected maternity professionals in 18 teams were videoed managing a patient-actor with a simulated emergency. The trained patient-actor assessed the quality of staff-patient interaction. Clinicians scored teams for their teamwork skills and behaviors. RESULTS: There was significant variation in staff-patient interaction, with some teams not having exchanged a single word and others striving to interact with the patient-actor in the heat of the emergency. There was significant correlation between patient-actor perceptions of communication, respect, and safety and individual and team behaviors: number, duration, and content of communication episodes, as well as generic teamwork skills and teamwork behaviors. The patient-actor perception of safety was better when the content of the communication episodes with them included certain items of information, but most teams failed to communicate these to the patient-actor. CONCLUSION: Some aspects of staff-patient interaction and teamwork during management of a simulated emergency varied significantly and were often inadequate in this study, indicating a need for better training of individuals and teams.

The use of simulation to teach clinical skills in obstetrics.

Obstetrical practice demands sensitivity, clinical skill, and acumen. Obstetrical emergencies are rare occurrences and are most appropriately dealt with by experienced staff. Simulation provides an opportunity to gain this experience without patient risk and furthermore builds confidence and satisfaction amongst learners. There is an abundance of evidence to show the effectiveness of simulation training. Simulation has been demonstrated to reduce errors, increase knowledge, skills, communication and team working, and improve perinatal outcomes. Further research to measure the effect of training to identify what works, where and at what cost is needed. We explore the evidence for the use of simulation-based training across a broad range of obstetrical emergencies, promote collaboration amongst disciplines and discuss the formal introduction of simulation training into a curriculum. Reducing preventable harm in obstetrics is a priority for families and society at large and this article endeavors to highlight the role that simulation has to play.

The management of a simulated emergency: better teamwork, better performance.

OBJECTIVES: To determine whether team performance in a simulated emergency is related to generic teamwork skills and behaviours. METHODS: Design - Cross-sectional analysis of data from the Simulation and Fire-drill Evaluation (SaFE) randomised controlled trial. Setting - Six secondary and tertiary Maternity Units in Southwest England. Participants - 140 healthcare professionals, in 24 teams. Assessment - Blinded analysis of recorded simulations. Main outcome measures - Correlation of team performance (efficiency conducting key clinical actions, including the administration of an essential drug, magnesium), and generic teamwork scores (using a validated tool that assesses skills and behaviours, by Weller et al.). RESULTS: There was significant positive correlation between clinical efficiency and teamwork scores across all three dimensions; skills (Kendall's tau(b)=0.54, p<0.001), behaviours (tau(b)=0.41, p=0.001), and overall score (tau(b)=0.51, p<0.001). Better teams administered the essential drug 2½min more quickly (Mann-Whitney U, p<0.001). CONCLUSIONS: The clinical conduct of a simulated emergency was strongly linked to generic measures of teamwork. Further studies are needed to elucidate which aspects of team working are critical for team performance, to better inform training programs for multi-professional team working.