Objective
To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff.
Study Design
Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life suppport pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring.
Results
Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017).
Conclusion
Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event.
Maternal cardiac arrest, a rare and devastating obstetric emergency, is on the rise from 1 in 30,000 pregnancies reported in 2002 to 1 in 20,000 as of 2005. Survival rates during maternal cardiac arrest have been shown to be worse compared with survival rates of other adults, with rates as low as 6.9%. As maternal age increases, obesity rates soar and the number of pregnancy-related complication rises, these events may become even more common. Timely initiation of uninterrupted, properly performed chest compressions is the most critical step in successful resuscitation, as emphasized in new advanced cardiac life support (ACLS) guidelines. Yet, critical care teams may not be available in the first few minutes of maternal code and on arrival, they may be less familiar with pregnancy-related modifications. Thus the obstetric team must be prepared to promptly initiate cardiopulmonary resuscitation and share knowledge of pregnancy-specific modifications to resuscitative measures for successful outcome of mother and fetus. Among obstetric providers, the maternal-fetal medicine physician (MFM), often the first to initiate care of an unresponsive pregnant patient, may be also looked to as a consultant with crucial knowledge of pregnancy-related modifications to guide a resuscitation team.
Current ACLS requirements and training are insufficient for sustaining resuscitation skills. In the field of internal medicine, compared with traditional cardiopulmonary resuscitation training, simulation-based education has been demonstrated to be significantly more effective as a teaching tool and resulted in enhanced medical resident adherence to American Heart Association protocols during actual codes. Among obstetric providers substantial deficiencies in management of simulated maternal cardiac arrest were noted in the recent study by Lipman and colleagues.
In obstetrics, no study has demonstrated the use of simulation for improving the management of a pregnant women who have had a cardiac arrest. We hypothesize that a simulation-based program for MFM staff will improve knowledge, confidence and performance in the management of cardiac arrest. Our primary objective was to determine the impact of a simulation-based maternal cardiac arrest educational program on postintervention performance, knowledge, and confidence of MFM staff at our institution.
Materials and Methods
MFM attendings (n = 12) and fellows (n = 7) at a large academic institution participated in a standardized maternal cardiac arrest simulation program, which consisted of preintervention, intervention, and postintervention maternal cardiac arrest simulations. The program was designed and implemented by an interdisciplinary team including 2 critical care medicine attendings, 2 MFM attendings, an MFM fellow, and a general obstetrician. Before simulation, each provider was oriented to the simulation set up and equipment. Participants were not aware of what scenario they would encounter before each simulation as we have an ongoing comprehensive obstetric simulation program. All data collected were deidentified.
The intervention was developed after initial preintervention simulations identified deficiencies demonstrated by the participants. An intervention workshop consisted of an American Heart Association (AHA) basic life support session, ACLS didactic tailored to the management of pregnant women, followed by a simulation practice session. ACLS didactic was developed by an interdisciplinary team and was based on AHA guidelines. It consisted of review of basic rhythms producing pulselessness, recognition of shockable vs nonshockable rhythms, ACLS pulseless arrest algorithm, initial airway management steps, and cardiac arrest pregnancy modifications. The workshop concluded with a simulation practice session guided by immediate feedback. Postintervention simulations were conducted in 3 week intervals after the simulation-based workshop.
Each pre- and postintervention simulation included a maternal cardiac arrest drill, a multiple choice test, and an attitudes/confidence survey, which were immediately followed by individualized debriefing session conducted by the MFM and critical care simulation team. The same clinical scenario was used for all simulations. Simulations took place in our fully stocked mock labor and delivery room. A high-fidelity simulator (NOELLE; Guamard Scientific, Coral Gables, FL) with capability to display maternal vital signs, cardiac rhythms, and continuous fetal monitoring was used for each simulation. All simulations were digitally recorded for debriefing, scoring, and timing of the events.
The scenario started with a confederate nurse calling the MFM physician (trainee) to the mock labor and delivery room for an evaluation of an unresponsive full-term pregnant patient with fetal heart rate at approximately 60 beats per minute. In addition, nursing, resident, and respiratory staff were available to assist in performing tasks, but these staff members were confederate actors and were instructed to only perform tasks as requested by the trainee. If requested, cardiac monitoring displayed ventricular fibrillation. If no defibrillation was requested by 4 minutes, the rhythm changed to asystole, and if defibrillation was requested, after the shock was administered asystole ensued. After 8 minutes, the scenario ended with programmed maternal mortality. The multiple-choice test, administered immediately after each simulation, consisted of 9 questions focused on pregnancy-related modifications of cardiac arrest management. An attitudes and confidence survey was administered next, followed by individualized debriefing of trainee performance. Our checklist, developed by our interdisciplinary team, was used for debriefing and consisted of a maternal performance score (9 pregnancy-related modifications in the management of cardiac arrest; Figure 1 ) and a critical care performance score (16 tasks; Figure 2 ) . The pregnancy modifications portion was based on AHA guidelines, part 10.8 (cardiac arrest associated with pregnancy), unchanged from 2010 guidelines ( Figure 1 ). Sixteen critical care tasks were adopted from AHA guidelines, part 7.2 (management of cardiac arrest). Eleven initial airway management tasks included in the critical care performance portion of a checklist were previously validated ( Figure 2 ). Response to the confidence question “ I feel confident in my ability to manage maternal code” was assessed based on a Likert scale from 0 to 7 (strongly disagree being 0 and strongly agree being 7).
