THE USE OF SIMULATION IN OBSTETRIC ANESTHESIA · THE USE OF SIMULATION IN OBSTETRIC ANESTHESIA...

THE USE OF SIMULATION IN THE USE OF SIMULATION IN OBSTETRIC ANESTHESIAOBSTETRIC ANESTHESIA

Georges Georges SavoldelliSavoldelli , MD, , MD, MEdMEdService dService d ’’AnesthAnesth éésiologiesiologie

Hôpitaux Universitaires de GenHôpitaux Universitaires de Gen èèveve

Annual Meeting SGAR/SSARAnnual Meeting SGAR/SSARSatellite Meeting ASAO/SAOASatellite Meeting ASAO/SAOA

Fribourg, Oct 30Fribourg, Oct 30 thth 20082008

La La «« machinemachine »» de Madame du de Madame du CoudrayCoudrayXVIIIXVIIIthth Century; MusCentury; Mus éée Flaubert de Flaubert d ’’histoire de la mhistoire de la m éédecine, Rouendecine, Rouen

Plan

�� What is simulation ?What is simulation ?

�� Why should we use simulationWhy should we use simulation --based training ?based training ?

�� Challenges in obstetric anesthesiaChallenges in obstetric anesthesia

�� Simulation in obstetric anesthesiaSimulation in obstetric anesthesia

�� ConclusionsConclusions

Simulation is…

�� A situation or environment created to allow A situation or environment created to allow persons to experience a representation of real persons to experience a representation of real events for the purpose of: events for the purpose of:

–– LearningLearning–– PracticePractice–– Evaluation / TestingEvaluation / Testing–– Gaining understanding of systemsGaining understanding of systems–– Gaining understanding of human actionsGaining understanding of human actions

(Harward CMS Definition)

Simulation allows...

�� The creation of a safe environment in which to:The creation of a safe environment in which to:

–– Teach, learn and practice Teach, learn and practice �� Technical skillsTechnical skills�� Non technical skillsNon technical skills�� Responses to both common and rare emergenciesResponses to both common and rare emergencies

–– Elicit responses to clinical scenarios in order to identify areaElicit responses to clinical scenarios in order to identify area s s for improvement at the level offor improvement at the level of

�� Individuals, teams and systemsIndividuals, teams and systems

–– Promote reflection and provide corrective feedbackPromote reflection and provide corrective feedback–– Explore end results of errorsExplore end results of errors–– Trial run new procedures and/or processesTrial run new procedures and/or processes

The spectrum of medical simulators

Ziv A, Acad Med 2003

Computer driven, fullComputer driven, full --length length mannequins. Simulated anatomy mannequins. Simulated anatomy and physiology. Lifelike setting.and physiology. Lifelike setting.

Realistic patient simulatorsRealistic patient simulators

HiHi--fi visual, audio, touch cues. fi visual, audio, touch cues. Virtual reality devices.Virtual reality devices.

Complex task trainersComplex task trainers

Programs to teach and assess Programs to teach and assess clinical knowledge, PBL, clinical knowledge, PBL, decisiondecision --making, making, managementmanagement ……..

ScreenScreen --based computer based computer simulatorssimulators

Actors trained to roleActors trained to role --play play patientspatients

Simulated/standardized patientSimulated/standardized patient

Models or mannequinsModels or mannequinsLowLow --tech simulatorstech simulators

Description/examplesDescription/examplesTool or approachTool or approach

Full scale realistic patient simulators

Debriefing room

Control room

High fidelity mannequin + simulated environment

Plan


�� Why should we use simulationWhy should we use simulation --based training ?based training ?




Why should we use simulation-based training ?

Educational rationaleEducational rationale

�� Principles of Principles of ““ Adult learningAdult learning ””–– Contextual learningContextual learning–– Experiential learningExperiential learning–– Reflective practiceReflective practice

�� Other reasons:Other reasons:–– Specific competencesSpecific competences–– Possibility to repeat the exercises (drills) Possibility to repeat the exercises (drills) –– Rare eventsRare events

The experiential cycle in simulation

Simulation experience

Reflection andinterpretation

Compare to existing

knowledge

Formation ofnew construct

1010--2020’’

DDéébriefingbriefing4545’’--6060’’

Why should we use simulation-based training ?

�� PsychoPsycho --cognitive argumentscognitive arguments–– Memory and emotionsMemory and emotions

�� Safety and risk managementSafety and risk management–– No risk for the patients No risk for the patients –– Desired outcomes = improved safety and patient careDesired outcomes = improved safety and patient care

““ To err is humanTo err is human ”” Institute of Medicine, 1999Institute of Medicine, 1999

�� Ethical imperativeEthical imperative

Plan


�� Why should we use simulation training ?Why should we use simulation training ?




The labor and delivery suite:A challenging environment

Characterized by:Characterized by:�� Acute stressAcute stress�� Heavy workloadHeavy workload�� 2 (or more) patients2 (or more) patients�� High stakes for decisions High stakes for decisions

and actions errorsand actions errors

Requires intense:Requires intense:�� Planning and anticipationPlanning and anticipation�� Error free vigilanceError free vigilance�� Effective CommunicationEffective Communication�� Effective multidisciplinary Effective multidisciplinary

teamwork teamwork

Ex Utero Intrapartum TreatmentKern C et al, SMW 2007

Planning / preparationAnticipationCoordination

Joint Commission in the US

Communication and teamwork issues are the Communication and teamwork issues are the most common contributors to:most common contributors to:

�� Unexpected Unexpected perinatalperinatal deaths and injuriesdeaths and injuries

�� Unexpected maternal deaths and injuriesUnexpected maternal deaths and injuries

Risk reduction in obstetric practice requires training in :

� Obstetric and neonatal emergencies (“fire drills”)

� Multidisciplinary team working

� Human factors

How can we improve teamwork in obstetric ?

� Didactic sessions are effective to introduce teamwork concepts and influence safety attitudeEx: “The ENSEMBLE Project at the HUG”

Haller G et al, International Journal for Quality i n Health Care , 2008

� However: ““ Translation of teamwork concepts Translation of teamwork concepts into clinical behaviors into clinical behaviors ……requires a deeper level requires a deeper level of integration and hands on experience through of integration and hands on experience through clinical team simulations/drills combined with a clinical team simulations/drills combined with a structured curriculumstructured curriculum …”…”

Guise JM and Segel S, Best Pract & Res Clin Obstet Gyna ecol 2007

Plan






� At HUG ≈ 1% of the CS are performed under GA !

� ≈ 10/4000 deliveries/year

� → Residents training may be insufficient and inadequate

� Simulation drills may complement clinical teaching

Scavone B et al, Anesthesiology 2006

Example of complex procedural skills:GA for emergency CS

Simulation and nonSimulation and non --technical skillstechnical skills

Anesthesia Residents (n=20)

Debriefing #1Session #1

Debriefing #3Session #31 month1 month

Debriefing #2Session #21 month1 month

Evaluation of technical by blind Evaluation of technical by blind raters using the ANTS scale systemraters using the ANTS scale system

Improvement in anesthesia trainees’non-technical skills

Improving multidisciplinary teamwork and communication at the HUG

�� Simulated scenarios to complement existing Simulated scenarios to complement existing didactic trainingdidactic training

�� Participants: Participants: –– ObstetriciansObstetricians–– MidwivesMidwives–– Anesthesiologists, Anesthesiologists, –– Nurse anesthetists, Nurse anesthetists, –– OR nursesOR nurses–– pediatricianspediatricians

Objectives of the session :

�� Highlight and discuss teamwork issues and Highlight and discuss teamwork issues and Crisis Resource Management principlesCrisis Resource Management principles during during critical obstetric emergenciescritical obstetric emergencies

�� Identify areas of improvementIdentify areas of improvement–– CommunicationCommunication–– CoordinationCoordination–– Cognitive biasCognitive bias–– New strategiesNew strategies

SBAR mnemonics

Effective SBAR communicationEffective SBAR communication

Scenario script:Scenario script:

33 year33 year --old G1 P0old G1 P0Refuses epidural analgesiaRefuses epidural analgesia

Umbilical cord Umbilical cord prolapseprolapseEmergency CS in the delivery roomEmergency CS in the delivery room

Effective SBAR communicationEffective SBAR communicationSituation: Situation: ““We have a cord We have a cord prolapseprolapse””Background: Background: ““ All OR are busyAll OR are busy ””Assessment: Assessment: ““ We have to do the CS hereWe have to do the CS here ””Recommendation: Recommendation: ““ Put her off to sleep ! Put her off to sleep ! ””

Effective SBAR communication

� Situation: “We have a cord prolapse”

� Background: “All OR are busy”

� Assessment: “We have to do the CS here”

� Recommendation: “Put her off to sleep ! ”

Communication and coordination

Lack of communicationLack of communication

↓↓

Leading to poor coordinationLeading to poor coordination

CRM and communicationCRM and communication

MeantMeant ……Is not saidIs not said

SaidSaid ……Is not heardIs not heard

HeardHeard ……Is not understoodIs not understood

UnderstoodUnderstood ……Is not done !Is not done !

This is true for Sender and Receiver !This is true for Sender and Receiver !

Closed loop Closed loop communicationcommunication

Une Une éétude rtude r éétrospectivetrospective

�� Retrospective cohort studyRetrospective cohort study–– All new born singleton from 1998 to 2003 All new born singleton from 1998 to 2003

�� In 2000 teaching Intervention: In 2000 teaching Intervention: –– 1 annual day multidisciplinary training1 annual day multidisciplinary training–– Didactic + interactive (CTG, EFM guidelines, case bas e Didactic + interactive (CTG, EFM guidelines, case bas e

discussion)discussion)–– HandsHands --on sessions : 6 scenarios on sessions : 6 scenarios (Shoulder (Shoulder dystociadystocia , PPH, , PPH,

EclampsiaEclampsia , Twins, Breech, Adult and neonatal resuscitation), Twins, Breech, Adult and neonatal resuscitation)

�� Outcome measures (preOutcome measures (pre --post intervention): post intervention): –– APGAR score at 5APGAR score at 5 ’’ ≤≤ 66–– Neonatal HypoxicNeonatal Hypoxic --ischeamicischeamic --encephalopathy (HIE)encephalopathy (HIE)

BJOG 2006

Results

0.53 (0.240.53 (0.24––1.13)1.13)11 (10.0)11 (10.0)16 (19.0)16 (19.0)Mod /severe HIEMod /severe HIEnn (rate/10,000)(rate/10,000)

0.50 (0.260.50 (0.26––0.95)0.95)15 (13.6)15 (13.6)23 (27.3)23 (27.3)HIEHIEnn (rate / 10,000)(rate / 10,000)

0.51 (0.350.51 (0.35––0.74)0.74)49 (44.4)49 (44.4)73 (86.6)73 (86.6)55’’ ApgarApgar ≤≤ 6, 6, nn (rate / 10,000)(rate / 10,000)

Relative Relative riskrisk20012001––2003 2003 ((nn= 11,030)= 11,030)

19981998––1999 1999 ((nn= 8430)= 8430)

Plan






Conclusions : Simulation in obstetric anesthesia …

�� is a useful educational techniqueis a useful educational technique

�� can be used to teach procedural and noncan be used to teach procedural and non --technical skillstechnical skills

�� is a promising tool to foster teamwork and communicati onis a promising tool to foster teamwork and communicati on

�� its use needs to be tailored according to:its use needs to be tailored according to:

–– Learning objectivesLearning objectives

–– The level of training of the participantsThe level of training of the participants

�� needs to be integrated in a broader curriculumneeds to be integrated in a broader curriculum

�� to fulfill these objectives, we need :to fulfill these objectives, we need :

–– Development of regional/national network Development of regional/national network

–– Support from our specialty societySupport from our specialty society ……

Thank you for your attention !Thank you for your attention !

http://simulationmedicale.hughttp://simulationmedicale.hug --ge.ch/ge.ch/

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