Leading change in practice: how "longitudinal prebriefing" nurtures and sustains in situ simulation programs.

In situ simulation (ISS) programs deliver patient safety benefits to healthcare systems, however, face many challenges in both implementation and sustainability. Prebriefing is conducted immediately prior to a simulation activity to enhance engagement with the learning activity, but is not sufficient to embed and sustain an ISS program. Longer-term and broader change leadership is required to engage colleagues, secure time and resources, and sustain an in situ simulation program. No framework currently exists to describe this process for ISS programs. This manuscript presents a framework derived from the analysis of three successful ISS program implementations across different hospital systems. We describe eight change leadership steps adapted from Kotter's change management theory, used to sustainably implement the ISS programs analyzed. These steps include the following: (1) identifying goals of key stakeholders, (2) engaging a multi-professional team, (3) creating a shared vision, (4) communicating the vision effectively, (5) energizing participants and enabling program participation, (6) identifying and celebrating early success, (7) closing the loop on early program successes, and (8) embedding simulation in organizational culture and operations. We describe this process as a "longitudinal prebrief," a framework which provides a step-by-step guide to engage colleagues and sustain successful implementation of ISS.

Coleadership in Maternity Teams, a Randomized, Counterbalanced, Crossover Trial in Simulation.

OBJECTIVE: This study aimed to measure the effect of a coleadership model on team performance compared with singular leadership model in simulated maternity emergencies. METHODS: A randomized, counterbalanced, crossover trial was performed at 2 tertiary maternity hospitals. Teams of obstetric physicians and nurse/midwives responded to 2 simulated maternity emergencies in either a singular or coleadership model. The primary outcome measure was teamwork rated with the Auckland Team Behavior tool. Secondary outcome measures included clinical performance (completion of critical tasks, time to critical intervention, documentation), self-rated teamwork (TEAM tool) and workload. Participants also answered a survey assessing their views on the coleadership model. Paired t tests and mixed-effects linear regression considering team as a random effect were used to estimate the unadjusted and adjusted associations between leadership model and the outcomes of interest. RESULTS: There was no difference between leadership models for the primary outcome of teamwork (5.3 vs. 5.3, P = 0.91). Clinical outcome measures and self-rated teamwork scores were also similar. Team leaders reported higher workload than other team members, but these were not different between the leadership models. Participants viewed coleadership positively despite no measured objective evidence of benefit. CONCLUSIONS: A coleadership model did not lead to a difference in team performance within simulated maternity emergencies. Despite this, participants viewed coleadership positively.

Clinicians' attitudes towards a co-leadership structure for maternity emergency teams: An interview study.

Shared leadership improves team performance in many domains and is present in some interprofessional healthcare teams. Despite the dominant paradigm of a singular obstetrician leader in maternity emergencies, co-leadership, a specific form of shared leadership, has been identified as a potentially beneficial to clinical care. This qualitative interview study addresses the gaps in knowledge regarding clinician attitudes toward co-leadership and how a co-leadership structure might be implemented within a maternity care setting. Twenty-five clinicians (midwives, obstetricians and anaesthetists) working in the birthing units of two tertiary maternity units were interviewed and a conventional content analysis conducted. Clinicians viewed co-leadership as potentially beneficial to patient care through improved leadership performance and co-leader back up behavior. Implementation of co-leadership was thought to require a supportive organizational culture, agreed patient management protocols and the participation in simulation training. Enacting co-leadership required adaptable leadership sharing practices, effective communication, and high levels of trust between the co-leaders. These findings inform the future implementation strategies for co-leadership in interprofessional healthcare teams.

The impact on obstetric and perinatal outcomes in term infants following the introduction of a colour-coded, hierarchical cardiotocography classification system: A retrospective non-inferiority study.

BACKGROUND: Queensland introduced a colour-coded cardiotocograph (CTG) classification system (green, blue, yellow and red) to complement the Royal Australian and New Zealand College of Obstetricians and Gynaecologists prose-based classification system of 'low, unlikely, maybe or likely' fetal compromise. AIMS: The aim of the study was to determine the clinical impact of the introduction of the colour-coded CTG classification system compared to the prose-based system. We hypothesised there would be no change in the rate of operative delivery for intrapartum fetal compromise (OD-IFC). MATERIALS AND METHODS: This retrospective non-inferiority study from November 2014 to May 2018 used routinely collected data from the Mater Mother's Hospital. Non-insured women with a singleton, non-anomalous, cephalic fetus at term, attempting a vaginal birth with continuous intrapartum CTG were included. The primary outcome was OD-IFC. Secondary outcomes included various obstetric and perinatal outcomes. Non-inferiority analysis was performed with a pre-specified non-inferiority margin of 2% risk difference. RESULTS: Eleven thousand seven hundred and twenty-seven participants were included. The OD-IFC rate was similar across the study groups (prose-based 15.1% vs colour-coded 15.3%, adjusted odds ratio (aOR) 1.02, 95% CI 0.93-1.13) with the adjusted risk difference of 0.29% (95% CI -0.98 to 1.56), which did not exceed the inferiority margin. There were more spontaneous (aOR 1.11, 95% CI 1.04-1.19) and fewer instrumental (aOR 0.87, 95% CI 0.80-0.95) vaginal births in the colour-coded cohort. There were no differences in neonatal outcomes. CONCLUSIONS: Reassuringly, the colour-coded CTG classification system was non-inferior to the prose-based system, did not influence OD-IFC but was associated with more spontaneous vaginal deliveries.

Implementing the transvaginal ultrasound simulation training (TRUSST) programme for obstetric registrars.

BACKGROUND: Transvaginal ultrasound (TVUS) training opportunities are limited due to its intimate nature; however, TVUS is an important component of early pregnancy assessment. Simulation can bridge this learning gap. AIM: To describe and measure the effect of a transvaginal ultrasound simulation programme for obstetric registrars. MATERIALS AND METHODS: The transvaginal ultrasound simulation training (TRUSST) curriculum consisted of supported practice using virtual reality transvaginal simulators (ScanTrainer, Medaphor) and communication skills training to assist obstetric registrars in obtaining required competencies to accurately and holistically care for women with early pregnancy complications. Trainee experience of live transvaginal scanning was evaluated with a questionnaire. Programme evaluation was by pre-post self-reported confidence level and objective pre-post training assessment using Objective Structured Assessment of Ultrasound Skills (OSAUS) and modified Royal Australian and New Zealand College of Obstetrics and Gynaecology assessment scores. Quantitative data was compared using paired t tests. RESULTS: Fifteen obstetric registrars completed the programme. Numbers of performed live transvaginal ultrasound by trainees were low. Participants reported an increase in confidence level in performing a TVUS following training: mean pre score 1.6/5, mean post score 3/5. Objective assessments improved significantly across both OSAUS and RANZCOG scores following training; mean improvement scores 7.6 points (95% CI 6.2-8.9, p < 0.05) and 32.5 (95% CI 26.4-38.6, p < 0.05) respectively. It was noted that scores for a systematic approach and documentation were most improved: 1.9 (95% CI 1.4-2.5, p < 0.05) and 2.1 (95% CI 1.5-2.7, p < 0.05) respectively. CONCLUSION: The implementation of a simulation-based training curriculum resulted in improved confidence and ability in TVUS scanning, especially with regard to a systematic approach and documentation.

Impact of simulation training on decision to delivery interval in cord prolapse.

Background: Umbilical cord prolapse is a rare obstetric emergency requiring rapid coordination of a multidisciplinary team to effect urgent delivery. The decision to delivery interval (DDI) is a marker of quality of teamwork. Multidisciplinary team simulation-based training can be used to improve clinical and teamwork performance. Aim: To assess the DDI for cord prolapse before and after the introduction of simulation-based training at a quaternary maternity unit in Australia. Method: A retrospective, observational cohort study comparing the DDI before and after the introduction of simulation-based training activities. The general linear model was used to estimate the association between DDI and simulation training while adjusting for potential confounders including model of care (public or private) and time of birth (regular or after hours). Results: After the introduction of simulation training, mean DDI decreased by 4.1 min (difference -4.1, 95% CI -6.2 to -1.9), after adjustment for confounding factors. Despite this, there was no difference in selected neonatal outcomes including Apgar score at 5 min and arterial cord pH. Conclusions: The introduction of simulation-based training was associated with a decrease in the DDI in the setting of cord prolapse.

Shared Leadership in Healthcare Action Teams: A Systematic Review.

OBJECTIVES: The aims of this review were to consolidate the reported literature describing shared leadership in healthcare action teams (HCATs) and to review the reported outcomes related to leadership sharing in healthcare emergencies. METHODS: A systematic search of the English language literature before November 2017 was performed using PsycINFO, MEDLINE, PubMed, CINAHL, and EMBASE. Articles describing sharing of leadership functions in HCATs were included. Healthcare teams performing routine work were excluded. Studies were reviewed for type of leadership sharing and sharing-related outcomes. RESULTS: Thirty-three articles met the inclusion criteria. A variety of shared leadership models were described across the following three categories: spontaneous collaboration, intuitive working relations, and institutionalized practices. While leadership sharing has the potential for both positive and negative influences on team performance, only six articles reported outcomes potentially attributable to shared leadership. CONCLUSIONS: Despite strong evidence for a positive relationship between shared leadership and team performance in other domains, there is limited literature describing shared leadership models in HCATs. The association between shared leadership and team performance in HCATs is a rich area for further investigation.

Caesarean scar ectopic pregnancy: Experience from an Australian tertiary centre.

BACKGROUND: Despite the rising incidence of caesarean scar pregnancy (CSP), as yet there are no consensus or evidence-based guidelines for management. AIMS: To review diagnosis, treatment and management of all women with CSP over a 5 year period at Mater Mothers' Hospital, Brisbane, Australia. MATERIALS AND METHODS: Retrospective cohort study of CSP between 2013-2018. Data reviewed included demographics, presenting symptoms, gestational age, ultrasound findings, human chorionic gonadotrophin levels, treatment success, complications, and if available, subsequent pregnancy outcomes. RESULTS: Twenty-eight women were treated for CSP during the study period. Initial diagnosis was delayed in ten (36%). Overall success rates of initial treatment were 22/28 (79%). Of the six cases of failed treatment, five had been treated with systemic methotrexate alone. All women requiring further intervention had fetal pole present, and 50% had fetal cardiac activity. Failure rate of systemic methotrexate alone was 5/11 (45%). Eleven women deemed appropriate for conservative management did not require further treatment or experience complications. Nine women had data available for subsequent pregnancies, of whom two developed placenta accreta. CONCLUSION: This study provides data that may assist in guideline development and decision-making for management of CSP. Conservative management in carefully selected women appeared to be safe. Nearly half of women treated with systemic methotrexate alone required another treatment modality, suggesting a role for intralesional treatment, particularly in the presence of fetal pole ± fetal cardiac activity. More than one in five women with documented subsequent pregnancies were diagnosed with placenta accreta.

Leadership sharing in maternity emergency teams: a retrospective cohort study in simulation.

Background: Shared leadership is associated with improved team performance in many domains, but little is understood about how leadership is shared spontaneously in maternity emergency teams, and if it is associated with improved team performance. Methods: A video analysis study of multidisciplinary teams attending a maternity emergency management course was performed at a simulation centre colocated with a tertiary maternity hospital. Sixteen teams responding to a simulated postpartum haemorrhage were analysed between November 2016 and November 2017. Videos were transcribed, and utterances coded for leadership type using a coding system developed a priori. Distribution of leadership utterances between team members was calculated using the Gini coefficient. Teamwork was assessed using validated tools and clinical performance was assessed by time to perform a critical intervention and a checklist of required tasks. Results: There was a significant sharing of leadership functions across the team despite the traditional recommendation for a singular leader, with the dominant leader only accounting for 58% of leadership utterances. There was no significant difference in Auckland Team Assessment Tool scores between high and low leadership sharing teams (5.02 vs 4.96, p=0.574). Time to critical intervention was shorter in low leadership sharing teams (193 s vs 312 s, p=0.018) but checklist completion did not differ significantly. Teams with better clinical performance had fewer leadership utterances beyond the dominant two leaders compared with poorer performing teams. Conclusions: Leadership is spontaneously shared in maternity emergency teams despite the recommendation for singular leadership. Spontaneous leadership emerging from multiple team members does not appear to be associated with the improvements in team performance seen in other domains.

Midwifery leadership in maternity emergencies: a video analysis.

Maternity emergencies require effective leadership due to their time-critical high stakes nature, and like many emergency teams are recommended to have a singular leader. Midwives possess many of the skills required for leadership, but the extent to which they contribute to leadership in emergencies is unknown. In this video analysis study of 16 interprofessional teams responding to a simulated post-partum hemorrhage, a functional view of leadership was applied to determine midwifery contribution to leadership. The number and type of leadership utterances by team members during an emergency response was assessed, and midwifery and doctor leadership utterances compared. Midwives contributed just over 40% of all leadership utterances, indicating the occurrence of interprofessional shared leadership, despite the recommendation for a singular leadership. While the number of leadership utterances per scenario was similar for midwives and doctors, midwives contributed less to utterances of a clinical nature compared to doctors but a similar amount of non-clinical leadership. Further exploration of the factors which influence midwifery leadership in emergencies and the impact it may have on patient care is warranted.

Simulation-based educational package to improve delivery of the deeply impacted fetal head at caesarean section.

Deeply impacted fetal head at caesarean section at full dilation is a rare obstetric emergency, and exposure for trainees can be limited. We aimed to pilot and evaluate a hospital-based training program incorporating mastery learning principles for trainees performing caesarean section at full dilation. We demonstrated improvements in knowledge, skills and self-confidence, and feel that this educational package shows promise as an important component of obstetric training, and warrants further exploration in the future.

Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers.

BACKGROUND: Lack of time and access to equipment are recognised barriers to simulation training. AIM: To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees. METHOD: Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy). RESULTS: Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation. CONCLUSION: A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

Trainee Performance in Loop Electrosurgical Excision Procedure (LEEP) After Simulation Training.

OBJECTIVE: The aim of the study was to review the performance of trainees in loop electrosurgical excision procedure (LEEP) procedures after the introduction of a simulation training program. MATERIALS AND METHOD: A simulation training program was introduced in September 2016 for gynecology trainees at the study institution. Trainees were encouraged to perform at least 3 simulated LEEP procedures before operating. For a 12-month period after the introduction of training, data on operating time and specimen quality measures of clear margin status, adequate depth, and absence of fragmentation were reviewed. This was compared with a 12-month period before simulation training (from September 2014-September 2015). Trainees were surveyed for feedback on the training. RESULTS: In total, 135 LEEP procedures were reviewed: 68 before and 67 after simulator training. Trainee specimens after training were more likely to be nonfragmented (89.2% vs 55.9%, p = .003), have clear margins (72.2% vs 41.9%, p = .015), and meet "all criteria" (46% vs 20.6%, p = .043) than trainee specimens before training. There was no change in depth adequacy (70.3% vs 67.7%, p = .99). Median trainee procedure time reduced from 18 minutes (interquartile range = 11-24) before training to 8 minutes after training (interquartile range = 6-11) (p = <0.001). There was no significant change in operating time or specimen quality from LEEP procedures performed by attendings (who did not use the simulator). Trainee and attending procedural outcomes were similar after training. Trainees had mostly positive views on the training, though reported time constraints as a barrier to simulation. CONCLUSIONS: After the introduction of an LEEP simulation training program, operative time and specimen quality from trainee procedures seemed to improve.

Is that realistic? The development of a realism assessment questionnaire and its application in appraising three simulators for a gynaecology procedure.

INTRODUCTION: There is no standard approach to determining the realism of a simulator, valuable information when planning simulation training. The aim of this research was to design a generic simulator realism questionnaire and investigate the contributions of different elements of simulator design to a user's impression of simulator realism and performance. METHODS: A questionnaire was designed with procedure-specific and non-procedure-specific (global) questions, grouped in subscales related to simulator structure and function. Three intrauterine contraceptive device (IUCD) simulators were selected for comparison. Participants were doctors of varying experience, who performed an IUCD insertion on each of the three models and used the questionnaire to rate the realism and importance of each aspect of the simulators. The questionnaire was evaluated by correlation between procedure-specific and global items and the correlation of these items to overall realism scores. Realism scores for each simulator were compared by Kruskal-Wallis and subsequent between-simulator comparison by Dunn's test. RESULTS: Global question scores were highly related to procedure-specific scores. Comparison revealed global item subscale scores were significantly different across models on each of the nine subscales (P < 0.001). Function items were rated of higher importance than structure items (mean function item importance 5.36 versus mean structure item importance 5.02; P = 0.009). CONCLUSIONS: The designed questionnaire was able to discriminate between the models for perceived simulator realism. Findings from this study may assist simulator design and inform future development of a generic questionnaire for assessing user perceptions of simulator realism.

Evaluation of a Low-Fidelity Surgical Simulator for Large Loop Excision of the Transformation Zone (LLETZ).

INTRODUCTION: Large loop excision of the transformation zone (LLETZ) is a common gynecological treatment for cervical dysplasia but can be challenging to teach. There is no widely adopted simulator for this procedure in Australia, so a new low-fidelity simulator was designed and evaluated. METHOD: A simulator for a LLETZ procedure was developed. Doctors (N = 29), varied in experience level in gynecology at a tertiary hospital, performed a LLETZ procedure using the simulator. The procedures were filmed, and two independent assessors rated the deidentified videos. The assessment involved a checklist (of crucial procedural steps) and global rating scale to evaluate whether the simulator facilitated the demonstration of LLETZ procedure skills. Participants completed a questionnaire evaluating the performance and utility of the simulator to determine participant perceptions of simulator realism and acceptability. RESULTS: The participant questionnaire revealed positive evaluations of realism and acceptability of the simulator. Performance scores were significantly different across experience levels (P < 0.001) with post hoc pairwise comparison between levels confirming significant differences between each group in assessed simulator performance for global rating scale and overall performance scores. The interrater reliability of the assessors was high (0.84). CONCLUSIONS: A low-fidelity simulator for a LLETZ procedure seems to adequately demonstrate procedural performance reflecting doctor experience level. Participant questionnaire responses were positive, supporting further evaluation of the simulator for use in training.

Evaluation of a standardized ward round in a prenatal inpatient setting.

OBJECTIVE: To evaluate the impact of incorporating a standardized ward round (SWR) tool including checklists for communication, safety, and efficiency into ward rounds. METHODS: A prospective non-randomized, before-and-after observational study was conducted at a tertiary maternity hospital in Brisbane, Australia, between October 1, 2014, and October 1, 2015. Obstetric team members performing prenatal ward rounds used role-specific lanyards prompting the structure of each consultation. Rounds were audited before and after the introduction of the SWR for safety checks, hand hygiene, the duration of patient encounters, and plan congruity. Patients completed a paper-based satisfaction survey. Results from before and after the introduction of the SWR were compared. RESULTS: There were 71 conventional ward rounds and 79 SWRs audited, and no difference was found in the mean duration of patient encounters (P=0.566). SWRs were associated with increased rates of each of the five safety checks being performed and of hand hygiene being observed correctly (all P<0.001). SWR was also associated with a greater proportion of patients indicating that they understood their plan of care. CONCLUSION: The use of a structured tool for ward rounds improved communication with patients, increased the frequency of safety checks being performed, and improved hand hygiene without prolonging ward rounds.

Simulation training in obstetrics and gynaecology: What's happening on the frontline?

BACKGROUND: Despite evidence supporting simulation training and awareness that trainee exposure to surgery is suboptimal, it is not known how simulation is being incorporated in obstetrics and gynaecology (O&G) training across Australia and New Zealand. AIM: To investigate the current availability and utilisation of simulation training, and the attitudes, perceived barriers and enablers towards simulation in Australia and New Zealand. METHOD: A survey was distributed to O&G trainees and fellows in Australia and New Zealand. The survey recorded demographic data, current exposure to simulation and beliefs about simulation training. RESULTS: The survey returned 624 responses (24.3%). Most trainees had access to at least one type of simulation (87%). Access to simulators was higher for trainees at tertiary hospitals (92% vs 76%). Few trainees had a simulation curriculum, allocated time or supervision for simulation training. 'Limited access' was the highest rated barrier to using simulation. Lack of time, other training priorities and cost were identified as further barriers. More than 80% of respondents believed simulation improves surgical skills, skills transfer to the operating theatre, and the addition of simulation to the RANZCOG curriculum would benefit trainees. However, a minority of respondents believed simulator proficiency should be shown prior to performing surgery. The need for a curriculum and supervision were highlighted as necessary supports for simulation training. CONCLUSIONS: Despite simulator availability, few trainees are supported by simulation training curricula, allocated time or supervision. Participants believed that simulation training benefits trainees and should be supported with a curriculum and teaching.

Clinical Outcome of Hypertensive Uveitis.

Purpose. To review the clinical outcome of patients with hypertensive uveitis. Methods. Retrospective review of uveitis patients with elevated intraocular pressure (IOP) > 25 mmHg and >1-year follow-up. Data are uveitis type, etiology, viral (VU) and nonviral uveitis (NVU), IOP, and medical and/or surgical treatment. Results. In 61 patients, IOP values are first 32.9 mmHg (SD: 9.0), highest 36.6 mmHg (SD: 9.9), 3 months after the first episode 19.54 mmHg (SD: 9.16), and end of follow-up 15.5 mmHg (SD: 6.24). Patients with VU (n = 25) were older (50.6 y/35.7 y, p = 0.014) and had more unilateral disease (100%/72.22% p = 0.004) than those with NVU (n = 36). Thirty patients (49.2%) had an elevated IOP before topical corticosteroid treatment. Patients with viral uveitis might have higher first elevated IOP (36.0/27.5 mmHg, p = 0,008) and maximal IOP (40.28/34.06 mmHg, p = 0.0148) but this was not significant when limited to the measurements before the use of topical corticosteroids (p = 0.260 and 0.160). Glaucoma occurred in 15 patients (24.59%) and was suspected in 11 (18.03%) without difference in viral and nonviral groups (p = 0.774). Conclusion. Patients with VU were older and had more unilateral hypertensive uveitis. Glaucoma frequently complicates hypertensive uveitis. Half of the patients had an elevated IOP before topical corticosteroid treatment.

Introducing a laparoscopic simulation training and credentialing program in gynaecology: an observational study.

BACKGROUND: Simulation training in laparoscopic surgery has been shown to improve surgical performance. AIMS: To describe the implementation of a laparoscopic simulation training and credentialing program for gynaecology registrars. MATERIALS AND METHODS: A pilot program consisting of protected, supervised laparoscopic simulation time, a tailored curriculum and a credentialing process, was developed and implemented. Quantitative measures assessing simulated surgical performance were measured over the simulation training period. Laparoscopic procedures requiring credentialing were assessed for both the frequency of a registrar being the primary operator and the duration of surgery and compared to a presimulation cohort. Qualitative measures regarding quality of surgical training were assessed pre- and postsimulation. RESULTS: Improvements were seen in simulated surgical performance in efficiency domains. Operative time for procedures requiring credentialing was reduced by 12%. Primary operator status in the operating theatre for registrars was unchanged. Registrar assessment of training quality improved. CONCLUSIONS: The introduction of a laparoscopic simulation training and credentialing program resulted in improvements in simulated performance, reduced operative time and improved registrar assessment of the quality of training.