Simulation development

All simulation programs are not created equal. Poorly constructed and executed simulations can reinforce bad habits. Unfortunately, many institutions spend large sums of money on simulation equipment before they develop their program. The simulator, no matter how sophisticated, does not run itself. Simulation is but one part of an education or safety program, not the focus of the program. The design of simulations must take into account who the learners are and what they must learn. Simulations that are designed to teach obstetricians the maneuvers to ensure delivery when a shoulder dystocia is encountered will be designed differently than simulations to improve the labor and delivery teams’ response to a shoulder dystocia on the unit. Strong programs include didactic, simulation, and debriefing sessions.

The didactic portion helps to ensure that participants have baseline knowledge about the subject matter. When done before the simulation, it helps to allay the participants’ fears that they will look foolish during the simulation. When done after the simulation, participants have the additional benefit of practical experience to apply to the didactic knowledge. The simulation portion allows the attendees to have practical hands-on experience. Adult learners, in particular, often retain more from doing than from hearing a lecture. Simulations can focus not only on particular skills, such as a forceps delivery, but also on communication and team-building exercises. Shoulder dystocia drills often combine both practice of specific maneuvers and exercise in communication skills.

The debriefing portion may serve the most important role. It provides a framework for open communication between multiple members of the team without the stress and pressure of defending a poor patient outcome. If the simulation is recorded digitally or filmed, it renders an unbiased look at what occurred. Often, participants will be surprised at their perception of what happened vs the recorded documentation. The debriefing allows the attendees both to evaluate their own performance and to discuss system issues that impair optimal outcome. The latter is particularly important when drills are performed in actual clinical spaces. As an example, we performed an on-site drill of a patient with eclampsia on our labor and delivery unit. Our simulated patient’s postpartum course was complicated by magnesium toxicity. During the drill, we identified that calcium gluconate had been removed from our automated drug dispersal system. As a result of the drill, this issue was rectified before a poor patient outcome occurred. A recent drill that involved a preterm delivery on our antepartum ward uncovered that our precipitous delivery kit lacked scissors, that there was not an immediately available neonatal Ambu bag, and that a radiant warmer was not available readily. Thus, these unit-based drills not only may thwart a potentially bad outcome but also may help to establish a culture of safety where a diverse group of personnel is empowered to identify and reduce risks.

When initiating a simulation program, the “Five Ws” can help guide its development. First, the “who” must be identified. Is the program geared to house staff, experienced physicians, or the entire team that is involved in patient care? The goals of the simulation project become clear once the targeted audience is established. In general, junior staff members will gain more from simulation than senior staff members. Goffman et al evaluated the use of a shoulder dystocia simulation program. The study involved both residents and attending staff members. A pretest was done, followed by a training session and posttest. Although only the residents showed significant improvement in procedural skills after the training session, both residents and attendings improved communication skills after simulation. Dupuis et al focused on correct usage of forceps. They designed a high-fidelity simulation model that tracked the tip of the forceps blade during placement. They studied both junior and senior providers and found that senior providers were more likely to place forceps correctly. Importantly, simulation training by junior providers resulted in improved placement of forceps.

Second, the “what” must be considered. There are a plethora of simulation programs from which to choose. Table 1 provides a partial outline of available topics that have been suggested by the American College of Obstetricians and Gynecologists (ACOG) Simulation Consortium and the Society for Maternal-Fetal Medicine Simulation Subcommittee. In addition to the choice of a topic, the type of simulation must be considered. Simulation projects can encompass actors, low-fidelity models, and high-fidelity models. An actor may be perfectly sufficient for an on-site eclampsia drill, whereas training for robotic surgery may require a more sophisticated high-fidelity simulator. Many simulations use hybrids or various combinations of low- and high-fidelity simulators and standardized patients. One group compared a low-fidelity model for shoulder dystocia (doll and pelvis) with a high-fidelity model that included feedback on the force that was used to effect delivery. At baseline, 43% of the participants were able to deliver the fetus. Those who underwent the low-fidelity training were able to deliver the simulated fetus 72% of the time after training, compared with 94% of the high-fidelity group. Simulation participants in the high-fidelity group also used less total applied force to deliver the fetus. Models that track the amount of traction that is used at the time of forceps delivery have also been developed. Leslie et al demonstrated an improved use of the correct forces after simulation training. Biomedical engineers at Johns Hopkins developed a simulator that measures strain on the fetus’ brachial plexus while undergoing shoulder dystocia. Researchers postulate that feedback of this information to obstetricians who perform simulated shoulder dystocia drills may lead to the achievement of vaginal delivery and the reduction of strain on the brachial plexus.

Third, the “where” must be determined. Deciding on location may be dependent on space and equipment constraints, however, on-site and off-site drills may achieve different aims. Off-site drills may have the advantage of having the participants’ undivided attention without competing clinical responsibilities. They can be scheduled to ensure that all staff participates in a simulation session. On-site drills not only provide valuable learning opportunities but also can test hospital systems and response times. For instance, during one practice session at our institution, it became apparent that the code team did not know where the Fetal Assessment Center was located. As a result, we have improved signage in the hospital to help prevent a similar event in the future. Ellis et al compared the effectiveness of training on-site vs at a simulation center for the management of eclampsia. The on-site training consisted of patient-actors and basic manikins, although the simulation center had an advanced patient simulator model.

Both groups underwent a didactic course as well. The simulations were repeated within 1-3 weeks of training. Both groups showed similar improvement in completing the expected tasks in a timely fashion. The authors suggested that the cost of using the simulation center, compared with the unit, was not justified by the measured outcomes.

Fourth, the “when” must be established. Although it is tempting to schedule sessions when staff members are already working, often the participants will be distracted by competing responsibilities. Depending on the size of the unit, drills may have to be cancelled because of lack of room when the patient volume is high. Ideally, simulations would occur during both scheduled and unscheduled sessions. Scheduled sessions ensure that all staff members gain exposure and are able to attend the entire program without interruptions. Impromptu on-site simulations test the system and allow participants to reinforce good practices in a realistic setting. We recommend compiling suggested drills with teaching points and a debriefing tool that is left in an accessible place on the unit. This resource will enable the charge nurse or attending physician to initiate drills that include off-shifts when there is downtime and will help to maximize involvement. Another question that arises is how often simulations must be repeated to ensure retention of knowledge. Crofts et al examined retention of skills after a shoulder dystocia training program. In addition to simulation practice, a didactic session was given. At baseline, 49% of the participants were able to deliver the fetus. Repeat testing was performed at 3 weeks with 82% success, at 6 months with 84% success, and at 1 year with 85% success. Maslovitz et al held a program for the management of eclampsia, postpartum hemorrhage, shoulder dystocia, and breech extraction. Follow-up testing that was performed at least 6 months after the training showed sustained improvement. Thus, how often simulations must be repeated is not clear and may very well vary with the clinical scenario that is being addressed.

Fifth, the “why” must be investigated. To be successful with any project, clear expectations should be set. These must be shared with the staff members so that they also understand the purpose of the simulation program. In general, resistance will be encountered with new initiatives. Unit drills should be unit goal specific. Nurses and physicians on our unit targeted reduction in the time from decision to perform cesarean section to delivery. Team simulations were designed subsequently and included a prolapsed umbilical cord in various areas of our hospital and clinics. Most people in health care genuinely wish to provide good care but may not see immediately the value of a simulation program. At one of our drills, one of the nurses burst into tears because she felt unprepared and was startled and embarrassed to be videotaped without previous warning. By setting mutual goals early on, participants will better understand the potential benefits of the project. The successful reduction of time from decision to cesarean delivery after simulated exercises sparked interest in further expansion of simulated drills at our institutions.