We evaluated the implementation of a labor and delivery unit team training program that included didactic sessions and simulation training with an active clinical unit. Over an 18-month follow-up time period, our team training program showed improvements in patient outcomes as well as in perceptions of patient safety including the dimensions of teamwork and communication.
The impetus for pursuing teamwork training in health care originated in the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System . This report emphasized the high incidence of medical errors in the US health system leading to iatrogenic patient morbidity and mortality. The Quality Interagency Coordination Task Force was established to develop a federal plan for reducing the number and severity of medical errors. Among its recommendations was the adaptation of crew resource management (CRM) training, part of team training, to medicine.
Derived from the military and aviation industries, the principles of team structure and closed-loop communication provide powerful tools in the high-risk, high-stakes environment of acute medical care. For over a decade, CRM has been applied in a variety of medical settings evaluating the ability to reduce medical error and improve patient safety. In addition, support for the use of medical simulation has gained momentum, most frequently for task training and clinical care of critically ill patients. Although medical simulation is less commonly used to teach the principles of CRM, the development of simulation-based team training programs is on the rise.
The use of simulation is growing in obstetrics. Training has usually been oriented toward provider skill development, focusing on a high-risk condition rather than developing comprehensive teamwork skills. Recent studies in the obstetrics literature have shown modest improvement in outcomes using CRM-based team training alone. Evaluating team training with the addition of simulation training with CRM training is still to be evaluated. The current study was undertaken to evaluate the implementation of a CRM-based curriculum that included simulation training on an active labor and delivery (L&D) unit. The evaluation incorporated assessments of provider attitudes and the patient experience, as well as objective medical outcomes. The objective of the project was to determine whether implementing an L&D unit team training program with simulation training improves patient outcomes as well as perceptions of safety and communication.
Materials and methods
Over the course of 30 months (July 2006 through December 2008), a prospective evaluation of CRM combined with simulation training to assess the impact on patient safety, provider attitudes, and patient outcomes was planned and implemented on an L&D unit with approximately 9200 births each year. Patient and provider data evaluating teamwork and patient safety perceptions were collected prior to initiating the training and compared with subsequent data collected 1 year later. Patient outcomes were assessed using data collected quarterly for 8 quarters prior to initiating the program and for the 6 quarters after implementing the program. All survey information was collected anonymously. Institutional review board approval was obtained to address any possible staff concerns and assure the integrity of the deidentified data collection system (Women and Infants Hospital of Rhode Island no. 06-0129).
The L&D team training planning committee consisted of risk managers and hospital administrators, as well as nurse managers, staff nurses, midwives, obstetricians (OBs), and anesthesiologists. The clinical simulation experts at the Rhode Island Hospital Medical Simulation Center provided guidance. The MedTeams team coordination course, provided by Dynamics Research Corp (Andover, MA) was selected as the CRM curriculum for teamwork training. A train-the-trainers approach was used that consisted of 2 days of didactics and hands-on training provided by staff from Dynamics Research Corp. During these sessions the future trainers, primarily physicians and nurses, learned about the philosophy of CRM as well as the design of the MedTeams curriculum. Instruction was provided regarding the best way to teach and convey the concepts of the program to the L&D unit staff. The didactic portion of the curriculum was delivered to the L&D unit staff by the nurse-physician training pairs.
Participants in both the classes and the simulations included members of the hospital physician staff who practiced obstetrics, certified nurse midwives, obstetrics and gynecology resident physicians, anesthesiology staff physicians, anesthesia certified nurse anesthetists, anesthesia registered nurses, L&D nurses, and unit secretaries.
Each didactic portion lasted approximately 4 hours, and was followed 3-7 days later by a 4-hour high-fidelity medical simulation and debriefing session. Fifteen sessions were scheduled to accommodate the entire L&D unit staff (day, afternoon, night, and weekend shifts). The goals of the simulation experience were to demonstrate the impact of CRM principles, and to enable participants to recognize how changes in their communication behaviors could affect patient care. A Gaumard obstetrical manikin (Noelle 565; Gaumard, Miami, FL) was integrated with a standard patient actor to simulate a live patient interaction. In-room facilitators guided participants through the scenario. Two different patient care scenarios were crafted to elicit the myriad of interactions among patients, clinicians, family members, and nonclinician health team members. Each scenario was scripted to require coordinated efforts and effective communication among nurses, midwives, secretaries, anesthesiologists, and OBs. Situation updates, transfers of leadership, and medication clarifications were essential components of the team’s interactions. Discussion with the patient and her family member was also an essential part of the scenario.
Each training session divided the group into 2 teams. One team participated in the first scenario while the second team acted as observers. After the first scenario was run and debriefed, the observers and participants exchanged roles. The second scenario was then run and debriefed. Each scenario was videotaped. All participants and observers took part in the debriefing session for each scenario. The videotape was used to guide the discussion. The debriefing focused on the clarity of communications with the goal of providing insight into current behaviors, and illustrating how standardized, closed-loop communications, adapted to their current practice, could prevent patient harm. The videotaped scenarios were destroyed for privacy protection immediately following the last debriefing.
Evaluation measures
To assess provider attitudes and perceptions of patient safety, we used a nationally recognized assessment tool, the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture. The survey was modified to reflect the L&D unit organizational structure while maintaining the integrity of the survey questions. The survey was administered to physicians, nurses, and administrative staff prior to initiating CRM training (February through May 2007) and 6 months after the L&D unit implemented the program (February through April 2008).
Data from the safety culture surveys were analyzed according to the documentation provided by AHRQ. The survey questions were grouped into 14 dimensions reflecting different aspects of safety culture. Each dimension was summarized as the number of positive responses divided by the number of questions in the domain. Positive responses included “strongly agree” and “agree” or “most of the time” and “always,” or, for negatively worded questions, “strongly disagree” and “disagree” or “never” and “rarely.” Surveys were excluded from analysis if <50% of questions were answered (6 of 193 pre-CRM and 2 of 122 post-CRM surveys) or if the responses were invariant (1 of 193 pre-CRM surveys). After these exclusions, 186 (96%) pre-CRM surveys and 120 (98%) post-CRM surveys remained for analysis. The proportion of positive responses in each dimension was compared between pre- and post-CRM surveys by the χ 2 test. Test statistics and 95% confidence intervals (CIs) were corrected for within-person clustering at each time point by Taylor series variance estimation. Individual questions on the surveys were compared by Fisher exact test. The analysis was repeated separately for OBs/perinatologists and L&D nurses. The surveys were anonymous to enhance participation; therefore, a paired data analysis was not possible. P values < .05 were considered statistically significant. Software (SAS, version 9.1; SAS Institute, Cary, NC) was used for data analysis.
The patient perspective on the culture of communication on the L&D unit was assessed by a survey that was modified from the MedTeams Quality of Care Survey. The patient surveys were distributed for 5 consecutive weeks in January through February 2007, which was prior to CRM training and for 5 weeks in January through February 2008, which was 6 months after the program’s implementation.
The Adverse Outcomes Index (AOI), a composite score of clinical outcomes, was evaluated quarterly with the 8 quarters prior to initiating the CRM team training program as the control time frame and 6 quarters following implementation as the outcome time frame. The 2 quarters during the time of implementing the CRM training were not included. The AOI has been used in previous studies evaluating obstetric unit team training programs and includes the number of deliveries identified with an adverse event divided by the total number of deliveries. The 10 types of adverse events are: maternal death, intrapartum or neonatal death of a neonate >2500 g (excluding cases with a congenital anomaly or fetal hydrops), uterine rupture, unexpected internal or external maternal transfer to an intensive care unit for a postpartum complication, birth trauma, return to the operating room or L&D, admission of neonate >2500 g and >37 weeks to neonatal intensive care unit within 1 day of birth for >24 hours (excluding cases with a congenital anomaly or fetal hydrops), Apgar score at 5 minutes <7 (excluding cases with a congenital anomaly or fetal hydrops), maternal blood transfusion, and third- or fourth-degree perineal laceration. These data and information were provided by the National Perinatal Information Center Quality Analytic Services, Providence, RI.
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