A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH).

BACKGROUND: Post-partum haemorrhage (PPH) is an obstetric emergency that requires effective teamwork under complex conditions. We explored healthcare team performance for women who suffered a PPH, focusing on relationships and culture as critical influences on teamwork behaviours and outcomes. METHODS: In collaboration with clinical teams, we implemented structural, process and relational interventions to improve teamwork in PPH cases. We were guided by the conceptual framework of Relational Coordination and used a mixed methods approach to data collection and analysis. We employed translational simulation as a central, but not singular, technique for enabling exploration and improvement. Key themes were identified from surveys, focus groups, simulation sessions, interviews, and personal communications over a 12-month period. RESULTS: Four overarching themes were identified: 1) Teamwork, clear roles and identified leadership are critical. 2) Relational factors powerfully underpin teamwork behaviours-shared goals, shared knowledge, and mutual respect. 3) Conflict and poor relationships can and should be actively explored and addressed to improve performance. 4) Simulation supports improved team performance through multifaceted mechanisms. One year after the project commenced, significant progress had been made in relationships and systems. Clinical outcomes have improved; despite unprecedented increase in labour ward activity, there has not been any increase in large PPHs. CONCLUSIONS: Teamwork, relationships, and the context of care can be actively shaped in partnership with clinicians to support high performance in maternity care. We present our multifaceted approach as a guide for leaders and clinicians in maternity teams, and as an exemplar for others enacting quality improvement in healthcare.

Test-enhanced learning improves learner attendance during a laparoscopic box trainer simulation program.

BACKGROUND: Laparoscopy is the gold standard approach for many surgical procedures, but it is a complex skill to learn. Laparoscopic simulation training may help, but it is unclear how to best engage trainees in these programs. Test-enhanced learning (TEL) uses regular, well-defined assessments of performance throughout the training phase of learning. AIM: The aim of this study was to assess the effects of TEL on a laparoscopic simulation program involving a cohort of medical student volunteers. MATERIALS AND METHODS: A prospective cohort study was performed with a convenience sample of 40 medical students. Students were recruited to participate in a ten-week laparoscopic simulation program. Twenty students participated in a laparoscopic surgical program with TEL ('TEL group'), and 20 students participated in a standard laparoscopic simulation program ('control group'). RESULTS: Attendance in the TEL group was significantly higher than in the standard group (71 vs 51.5%, P = 0.03). There was no difference between groups in mean time scores. Four themes were identified in qualitative data drawn from student surveys - personal traits and motivators, training context, clear goals and feedback enabling understanding of one's own performance. CONCLUSION: Testing laparoscopic skills throughout a learning program, in conjunction with individualised feedback and tracking of learning trajectory, increases trainee attendance. Laparoscopic simulation training programs are encouraged to reflect on the pedagogic framework in which their procedural skills training operates.

Are we 'gritty' enough? The importance of 'grit' in O&G training: Association of passion and perseverance with burnout, thriving and career progression.

BACKGROUND: Objective assessment of grit and its association with burnout in obstetrics and gynaecology (O&G) training is underexplored. AIM: This study utilises the Short Grit Scale and the Oldenburg Burnout Inventory to investigate the association of grit with burnout, thriving and career progression among O&G trainees and Fellows in Australia/New Zealand. MATERIALS AND METHODS: A cross-sectional survey of the RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) members was conducted. Participants were categorised by seniority level (core trainees, advanced trainees and Fellows). Mean grit and burnout scores were compared with one-way analyses of variance. Correlation between grit and burnout was estimated using Pearson's correlation coefficient. Logistic regression models were used to determine factors associated with high vs low burnout. Grit was categorised as low/medium/high for regression models. RESULTS: A total of 751 (26%) participants completed the survey. Fellows reported higher mean grit than core (P = 0.02) and advanced trainees (P = 0.03), and lower mean burnout than core trainees (P < 0.001). Moderate negative correlation was demonstrated between grit and burnout scores (r = -0.34). In the multivariable model, only seniority (adjusted adds ratio (OR): 0.40 for Fellows vs core trainees, P = 0.008) and grit levels (adjusted OR:4.52 for low versus high, P < 0.001; 2.32 for low vs medium, P = 0.001) were significantly associated with burnout. CONCLUSION: This study demonstrates the protective role of grit in combating burnout among RANZCOG trainees and Fellows. While further well-designed studies are warranted, findings from our study are expected to help the College in developing targeted interventions and subsequently minimise burnout-related adverse outcomes in high-risk groups.

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.

On the Sensitivity and Specificity of Postmortem Upper Respiratory Tract Testing for SARS-CoV-2.

BACKGROUND: Postmortem testing can improve our understanding of the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) if sufficiently sensitive and specific. METHODS: We investigated the postmortem sensitivity and specificity of reverse transcriptase polymerase chain reaction (PCR) testing on upper respiratory swabs using a dataset of everyone tested for SARS-CoV-2 before and after death in England, 1 March to 29 October 2020. We analyzed sensitivity in those with a positive test before death by time to postmortem test. We developed a multivariate model and conducted time-to-negativity survival analysis. For specificity, we analyzed those with a negative test in the week before death. RESULTS: Postmortem testing within a week after death had a sensitivity of 96.8% if the person had tested positive within a week before death. There was no effect of age, sex, or specimen type on sensitivity, but individuals with coronavirus disease 2019 (COVID-19)-related codes on their death certificate were 5.65 times more likely to test positive after death (95% confidence interval, 2.31-13.9). Specificity was 94.2%, increasing to 97.5% in individuals without COVID-19 on the death certificate. CONCLUSION: Postmortem testing has high sensitivity (96.8%) and specificity (94.2%) if performed within a week after death and could be a useful diagnostic tool.

COVID-19 vaginal delivery - A case report.

The novel coronavirus termed SARS-CoV-2 (COVID-19) is a major public health challenge. Many maternity units around the country are currently considering management protocols for these patients. We report a case from a tertiary Australian hospital describing an uncomplicated vaginal birth in a COVID-19 positive mother. To our knowledge this is also the first case described of a mother with COVID-19 not separated from her infant. Management provided supports the current Royal College of Obstetricians and Gynaecologists and World Health Organization guidelines suggesting that it is possible to consider rooming in post-delivery for COVID-19 positive parents. Encouragement of breastfeeding appears possible and safe when viral precautions are observed.

Preparing maternity for COVID-19: A translational simulation approach.

COVID-19 has posed major challenges for health care. Hospitals around the world have needed to rapidly prepare for the emerging pandemic. Translational simulation - simulation that is integrated and focused on emerging clinical priorities - offers numerous opportunities to aid in pandemic preparation. We describe our approach to preparing our institution's maternity services for the COVID-19 pandemic using translational simulation. We suggest lessons for providers of maternity services, and for those who support them through simulation activities.

Involving the consultant before fetal blood sampling.

BACKGROUND: Fetal scalp lactate (FSL) is used when the cardiotocography (CTG) is not normal in an attempt to reduce the false-positive rate and the likelihood of unnecessary intervention. Whilst the test has almost a 100% negative predictive value, the positive predictive value of this test is very low. AIMS: To measure the effect of introducing consultant obstetrician review of every abnormal CTG prior to the decision to perform FSL. MATERIALS AND METHODS: A retrospective cohort study was performed using routinely collected de-identified data. Mode of birth outcomes for women who had a continuous CTG in labour were compared in two equal time periods, 12 months before and after a change in hospital policy. Change in hospital policy dictated that FSL was only performed on a pathological CTG after consultant obstetrician review of the CTG. RESULTS: Consultant obstetrician review of CTG prior to FSL was associated with fewer FSL performed (1.7% vs 3.5%; P ≤ 0.01), fewer babies acidaemic at birth pH < 7.1 (0.8% vs 2.2%; P < 0.01), fewer caesarean sections for presumed fetal distress (CS for FD) (6.6% vs 8.1%; P = 0.05) and fewer instrumental births (17.6% vs 20%; P = 0.04). When adjusted for confounders, the change in policy was independently associated with a reduced likelihood of CS for FD (adjusted odds ratios = 0.78 (0.63-0.97); P = 0.03). CONCLUSIONS: A hospital policy whereby a consultant obstetrician reviews abnormal CTGs prior to performing FSL may help to increase the pretest probability and reduce the rate of CS for FD, as well as instrumental birth and unnecessary FSL.

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.

Watching the watchers: assessing the nature and extent of children's screen time using wearable cameras.

AIM: Children's screen use has increased rapidly in recent years, yet little is known about this use in real-time due to reliance on self-report or proxy data sources. Screens provide benefits such as educational content and social connection, but also pose health risks including obesity, depression, poor sleep and poor cognitive performance. In this cross-sectional observational study, we aimed to determine the nature and extent of children's after-school screen time using wearable cameras. METHOD: Children aged 11-13 years took part in the New Zealand Kids'Cam project in 2014/2015. Each child wore a camera that passively captured images of their surroundings every 7 seconds. Images from 108 children were manually coded. RESULTS: Children spent over a third of their time on screens, including over half their time after 8pm. Television accounted for the highest proportion of screen time (42.4%), followed by computers (32.0%), mobile devices (13.0%) and tablets (12.6%). Approximately 10% of children's screen time involved multiple screen use. CONCLUSION: Guidelines are needed to promote healthy screen time behaviour among children. Further research is also needed to monitor the impact of screens on children's wellbeing, including any socio-demographic differences, and to identify innovations to protect children from harm in the online space.

Translational simulation for rapid transformation of health services, using the example of the COVID-19 pandemic preparation.

Healthcare simulation has significant potential for helping health services to deal with the COVID-19 pandemic. Rapid changes to care pathways and processes needed for protection of staff and patients may be facilitated by a translational simulation approach-diagnosing changes needed, developing and testing new processes and then embedding new systems and teamwork through training. However, there are also practical constraints on running in situ simulations during a pandemic-the need for physical distancing, rigorous infection control for manikins and training equipment and awareness of heightened anxiety among simulation participants. We describe our institution's simulation strategy for COVID-19 preparation and reflect on the lessons learned-for simulation programs and for health services seeking to utilise translational simulation during and beyond the COVID-19 pandemic. We offer practical suggestions for a translational simulation strategy and simulation delivery within pandemic constraints. We also suggest simulation programs develop robust strategies, governance and relationships for managing change within institutions-balancing clinician engagement, systems engineering expertise and the power of translational simulation for diagnosing, testing and embedding changes.