The objective of this study was to evaluate the impact of an interdisciplinary team-training program in obstetric emergencies on identifying unsupportive institutional policies and systems-based practices. We implemented a qualitative study design with a purposive sample of interdisciplinary physicians, nurses, and ancillary allied health professionals from 4 specialties (n = 79) to conduct a 6-month, weekly simulation-based intervention for managing obstetric emergencies. Debriefing focused on identifying discrepancies between clinical practice and institutional policies. Our data yielded 5 categories of discrepancies between institutional or departmental policy and actual clinical practice. Specific institutional policies and system-based practices were recommended to health system administration for reevaluation. Simulation-based interdisciplinary team training can inform system-wide quality improvement objectives that could lead to increased patient safety.
In the United States, communication failures account for 72% of the sentinel events occurring in perinatal units. Simulation-based training can benefit patient safety initiatives by providing the opportunity to develop clinical competencies in the context of interdisciplinary practice around rare or infrequent clinical events where both individual and team performances are critical for preventing patient morbidity or mortality. The aim of simulation-based team training is to analyze teamwork during enactments of real-life patient scenarios, detect areas of deficiency or excess, and through immediate debriefing initiate performance improvements that will transfer to applied patient care. However, at this time, research evaluating the impact of interdisciplinary obstetric team training on systems-based practices is not well reported. The purpose of the this study was to evaluate the impact of an interdisciplinary team training program in obstetric emergencies on identifying and seeking to remedy existing systems-based practice weaknesses.
Materials and methods
We hypothesized that simulation-based interdisciplinary training would reveal system-level and specialty-specific procedural and policy conflicts with the potential to adversely impact patient care. We designed the OBEMAN (Obstetrics, Emergency Medicine, Anesthesiology, and Neonatology) Program as an intervention targeting interdisciplinary teams of physicians, nurses, and ancillary health professionals tasked with managing obstetric emergencies at the University of Michigan. The program received an exemption from our institutional review board. A sample of clinical professionals (n = 79) participated in the program, with equivalent representation from all targeted groups at each session. Teams met weekly for 2 hours over 6 months, with no more than 3 participants from each clinical specialty per week. The training included aspects of team-based reasoning and decision making, communication, management, and follow-up in the provision of clinical care for a pregnant patient and her fetus during an emergency event. In addition to the simulation-based sessions, we created a web-based reference portal that included links to institutional policies and procedures, departmental policies and procedures, state and federal regulations, and professional practice guidelines for each specialty involved in the program.
We designed presenting cases to include unusual and challenging attributes to explore system-based practices that are seldom evaluated in day-to-day patient care. Examples from the case library include a 43-year-old woman with multiple failed in vitro fertilization (IVF) pregnancies in preterm labor at 23 + 4 weeks; a 12-week pregnant 14-year-old girl presenting with injuries sustained from rape by a male relative; a 32-year-old woman at 28 + 6 weeks presenting with measles; a motor vehicle accident with multiple unconscious pregnant and pediatric patients to manage concurrently; a patient who refuses care against the recommendations of her providers; and other parallel situations requiring ancillary personnel and knowledge of institutional practices (policies, protocols, and procedures) that are infrequently used. All scenarios were built around obstetric emergencies presenting to the emergency department and were designed to require consultation from the participating departments, as well as ancillary specialty services such as respiratory therapy, social work, and SANE (Sexual Assault Nurse Examiner).
In addition to issues associated with clinical management, we emphasized the importance of working collaboratively to determine best practices that would inform system-level quality improvements. Participants engaged in debriefing activities after each case that were designed to identify and discuss systems-level strengths and challenges, and if merited provide recommendations for policy or procedural improvements. We used transcriptions from the debriefing sessions to identify system-level and specialty-specific practices, policies, and procedures that conflicted with each other or had the potential to adversely impact patient care. We describe these findings using narrative form, which is congruent with qualitative data.
Results
Transcripts from the debriefing sessions identified 5 main types of system-level and specialty-specific practices, policies, and procedures that could potentially cause conflict within the clinical team or adversely impact patient care. We named these categories and illustrate each type with an example below: (1) policies certatim, (2) policies impossibilia, (3) policies casualis, (4) policies oblivio, and (5) policies absens. The frequency with which an occurrence from each category arose during the obstetric and neonatal cases, and the total number of occurrences for each type during the 24 weeks of data collection is shown in Table . We prepared a report informing our health system administrators of our findings with recommendations for implementing change solutions to eliminate ineffective policies and consider formulating others where merited.
