Greetings from Stanford

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Greetings from Stanford
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Risk Management 101 Creating Culture Change on
the Labor Delivery Ward

• Kay Daniels, Obstetrician
• Steve Lipman, Anesthesiologist

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Maternal Mortality 2005
From World Health Organization, data from 2005,
www.who.int/whosis/mme_2005
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California Maternal Mortality Rate
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Lecture Outline

• 1. Why focus on obstetrical care?
• 2. What drivers exist to promote a culture
  change in this domain?
• 3. Does simulation team training work?
• 4. Lessons learned

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Meet your patient typical?
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Obesity Rates in the UK US
International Association for the Study of
Obesity, London, March 2008, Data from 2006 for
UK and 2003-4 for US, http//www.iotf.org/database
/documents/
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Our Practice Domain

• Stress
• Fatigue
• High stakes
• Time pressure
• Task saturation
• Auditory overload

• Two patients
• Language barrier
• High expectations
• Limited resources
• Multiple care teams
• Frantic spouse/family

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LD ED OR ICU
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Drivers for Change

• JCAHO- Sentinel Event Alert 30 dated July 21,
  2004
• (USA)
• Institute of Medicine 1999 To err is human
  building a safer health system. (USA)
• Building a safer NHS for patients. London
  Department of Health Review recommending
  improvements in patient safety (UK )
• CEMACH (UK)

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Case-related Maternal Mortality
From Hawkins JL, Koonin LM, Palmer SK, Gibbs CP.
Anesthesia-related deaths during obstetric
delivery in the United States, 1979-90.
Anesthesiology 199786277-84, and Hawkins JL,
Chang, Palmer, Callaghan, and Gibbs, A-10 Oral
Presentation, SOAP, May 1, 2008, Chicago, IL, USA
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Old/Current Culture

• See one Do one Teach One
• Possible corollary
• See one done Wrong
• Do 100 Wrong
• Teach them Wrong Forever

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New Culture

• See one
• Sim one correctly
• Teach correctly forever

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OBSim

• Our goal improve team performance
• LD training must include
• Obstetricians
• Anesthesiologists
• LD nurses

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Study ObjectiveDoes simulation work?

• We compared
• Traditionally trained teams
• Simulation trained teams
• 2 obstetrical crises
• shoulder dystocia
• eclampsia

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Training

• Traditional
• Lectures
• Videos
• Simulation
• No lectures/videos
• Training in the simulator

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Simulation versus Traditional Training Study

• Testing one month after training
• All tests videotaped
• Grading done by a blinded reviewer who was
  unaware of each teams mode of training

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LD Drill
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Performance testing Eclampsia
Technical Score (T14)
p0.032
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Performance testing Shoulder Dystocia
Technical Score (T14)
(p0.002)
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Conclusion

• Simulation trained teams demonstrated superior
  clinical skills as compared to traditional
  trained teams.

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OBSim Project Phase 1

• Would a change in the training paradigm be
  acceptable to our LD teams?
• Scenarios based on risk management and nursing
  educations input
• Shoulder dystocia
• Anaphylaxis with cardiac arrest in a laboring
  patient

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Phase 1 Culture Change

• Traditional nursing skills fair
• Lectures
• Workstations and posters
• New simulation program
• Learning objectives embedded in scenarios

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Survey says .
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How was this learning experience compared to
nursing skills fair ?

• More useful 48
• Less useful 1
• Equal 1
• ( RN responses only)

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Was it worth your time ?

• Yes 107
• N0 0
• No response 2

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Preferred modality of education

• Simulation/workshop(hands-on) 84
• Reading 6
• Lecture 5
• Computer 5

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Phase 2 LD Drills

• Can simulation reveal system errors on the unit?
• 2 simulated crises
• Crash cesarean
• Postpartum hemorrhage

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Moving patient
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System Errors

• Difficulty moving patient from room in stat
• Need to improve closed loop communication
• Poor workload distribution
• RRT page too slow
• Need emergency paper charting, computer too slow

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How are we addressing findings?

• Cordless fetal monitoring
• Model closed loop communication before each drill
• Emergency charting solution unknown
• Page operator instruction about RRT response time

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Workload Distribution
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Workload distribution
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WHAT IS HAPPENING ON YOUR UNIT ?

• Simulation can be used to reveal errors
• in any unit
• How can we improve?

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• Train like you Fight and Fight like you Train

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Testimonial

• On May 30th, I attended the OB Sim training
  during which one of our scenarios was shoulder
  dystociathe very next day at work in LD my
  exact same scenario would be replicated! I took
  care of a patientwho proceeded to have a three
  minute shoulder dystocia!
• I felt so much better equipped in my skills to
  handle this emergency situation as a result of my
  attendance at OB Sim. Communication among the
  team was very clear and the emergency was handled
  very smoothly.
• The outcome was very good (Apgars 79), I am
  convinced of the value and benefit of OB Sim
  validated by my own personal experience in the
  real LD setting.
• Thank you all who are involved in OB Sim for
  your dedicated time and effort in this wonderful
  program.

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Road blocks and Resources

• Clinicians
• Anecdotal view
• Risk Management
• Global view
• ROAD BLOCK OR RESOURCE

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Thank you for your attention