Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication. Anesthesia and analgesia 2016; 123 (5): 1181-1190
As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors' local experience with obstetric simulation drills and optimization of team communication.
View details for PubMedID 27749353
Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. International journal of obstetric anesthesia 2016; 25: 9-16
Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage.Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used.The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05).Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.
View details for DOI 10.1016/j.ijoa.2015.08.011
View details for PubMedID 26421705
An Update on the American Heart Association Scientific Statement on Cardiac Arrest in Pregnancy published in Circulation October 2015 Society of Obstetric Anesthesia & Perinatology. Society of Obstetric Anesthesia & Perinatology Winter 2016 Newsletter. 2016
Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation 2015; 132 (18): 1747-1773
This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.
View details for DOI 10.1161/CIR.0000000000000300
View details for PubMedID 26443610
Intact Survival After Obstetric Hemorrhage and 55 Minutes of Cardiopulmonary Resuscitation. A & A case reports 2015; 5 (1): 9-12
Cardiac arrest occurs in approximately 1:12,000 parturients. Among nonpregnant patients who have in-hospital cardiac arrest, those whose spontaneous circulation does not return within 15 to 20 minutes have a high risk of death and disability, so life support efforts are generally stopped after this period. However, among parturients, witnessed in-hospital arrest is often reversible and has a better prognosis. We describe a successful clinical outcome after maternal cardiac arrest and 55 minutes of advanced cardiac life support. This case underscores the importance of high-quality cardiopulmonary resuscitation and raises questions about the appropriate duration of resuscitation efforts in otherwise healthy young mothers with a potentially reversible cause of arrest.
View details for DOI 10.1213/XAA.0000000000000163
View details for PubMedID 26125692
The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy ANESTHESIA AND ANALGESIA 2014; 118 (5): 1003-1016
This consensus statement was commissioned in 2012 by the Board of Directors of the Society for Obstetric Anesthesia and Perinatology to improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest. The recommendations in this statement were designed to address the challenges of an actual event by emphasizing health care provider education, behavioral/communication strategies, latent systems errors, and periodic testing of performance. This statement also expands on, interprets, and discusses controversial aspects of material covered in the American Heart Association 2010 guidelines.
View details for DOI 10.1213/ANE.0000000000000171
View details for Web of Science ID 000335395900021
Multidisciplinary simulation drills improve efficiency of emergency medication retrieval. Obstetrics and gynecology 2014; 123: 143S-4S
Postpartum hemorrhage resulting from uterine atony is one of the leading causes of maternal morbidity. If initial treatment for atony is unsuccessful, second-line uterotonics must be administered immediately.A retrospective observational study was performed to evaluate barriers to the management of postpartum hemorrhage on our unit. Fourteen multidisciplinary teams participated in postpartum hemorrhage simulation drills. Actions in the labor room and the medication room were video-recorded for analysis. Postsimulation video review revealed multiple system errors delaying the process of obtaining the secondary uterotonics: 1) computer-generated delay in entering the patient's identification; and 2) multiple locations for the three medications. A "postpartum hemorrhage kit" was developed by pharmacy services, which included methylergonovine, carboprost, and misoprostol. All three medications were then placed in the refrigerator in an insulated box. These changes 1) allowed all medications to be removed in a kit in one step; 2) the kit could be retrieved more easily as a result of adjustments made in the identification process; and 3) the foam insulation kept the carboprost cooled as required. The postpartum hemorrhage simulation scenario was repeated to evaluate delivery of uterotonic medications with access to the postpartum hemorrhage kit.After the corrections, time to retrieval of all three uterotonic medications decreased significantly from 2 minutes and 16 seconds before use of the kit to 29 seconds with the kit.Simulated scenarios exposed correctable delays in the retrieval of emergency medications. Simulation drills can be used to detect system errors, improve system processes, and potentially reduce maternal morbidity and mortality.
View details for DOI 10.1097/01.AOG.0000447124.24190.ec
View details for PubMedID 24770020
Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance JOURNAL OF PERINATOLOGY 2013; 33 (4): 259-263
We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean.Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children's Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision.The median (interquartile range) from time zero until incision was 9min 27s (8:55 to 10:27min:s).In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery.
View details for DOI 10.1038/jp.2012.98
View details for Web of Science ID 000316833300002
View details for PubMedID 22858890
Transport Decreases the Quality of Cardiopulmonary Resuscitation During Simulated Maternal Cardiac Arrest ANESTHESIA AND ANALGESIA 2013; 116 (1): 162-167
The purpose of this study was to compare cardiopulmonary resuscitation (CPR) for simulated maternal cardiac arrest rendered during transport to the operating room with that rendered while stationary in the labor room. We hypothesized that the quality of CPR would deteriorate during transport.Twenty-six teams composed of 2 providers (obstetricians, nurses, or anesthesiologists) were randomized to perform CPR on the Laerdal Resusci Anne SkillReporter mannequin during transport or while stationary. The primary outcome measure was the percentage of correctly delivered compressions, defined as compression rate 100 beats per minute, correct sternal hand placement, compression depth 1.5 inches (3.8 cm), and proper release. Secondary outcomes included interruptions in compressions, position of providers relative to the mannequin during the transport phase, and ventilation tidal volume.The median (interquartile range) percentage of correctly rendered compressions during phase II was 32% (10%-63%) in the transport group and 93% (58%-100%) in the stationary group (P = 0.002, 95% confidence interval of mean difference = 22%-58%). The median (interquartile range) compression rates were 124 (110-140) beats per minute in the transport group and 123 (115-132) beats per minute in the stationary group (P = 0.531). Interruptions in CPR were observed in 92% of transport and 7% of stationary drills (P < 0.001, 95% confidence interval of difference = 61%-92%). During transport, 18 providers kneeled next to the mannequin, 2 straddled the mannequin, and 4 ran alongside the gurney. Median (interquartile range) tidal volume was 270 (166-430) mL in the transport group and 390 (232-513) mL in the stationary group (P = 0.03).Our data confirm our hypothesis and demonstrate that transport negatively affects the overall quality of resuscitation on a mannequin during simulated maternal arrest. These findings, together with previously published data on transport-related delays when moving from the labor room to the operating room further strengthen recommendations that perimortem cesarean delivery should be performed at the site of maternal cardiac arrest.
View details for DOI 10.1213/ANE.0b013e31826dd889
View details for Web of Science ID 000313145300020
Labor Room Setting Compared With the Operating Room for Simulated Perimortem Cesarean Delivery A Randomized Controlled Trial OBSTETRICS AND GYNECOLOGY 2011; 118 (5): 1090-1094
To compare the labor room and operating room for perimortem cesarean delivery during simulated maternal arrests occurring outside the operating room. We hypothesized transport to the operating room for perimortem cesarean delivery would delay incision and other important resuscitation milestones.We randomized 15 teams composed of obstetricians, nurses, anesthesiologists, and neonatal staff to perform perimortem cesarean delivery in the labor room or operating room. A manikin with an abdominal model overlay was used for simulated cesarean delivery. The scenario began in the labor room with maternal cardiopulmonary arrest and fetal bradycardia. The primary outcome was time to incision. Secondary outcomes included times to important milestones, percentage of tasks completed, and type of incision.The median (interquartile range) times from time zero to incision were 4:25 (3:59-4:50) and 7:53 (7:18-8:57) minutes in the labor room and operating room groups, respectively (P=.004). Fifty-seven percent of labor room teams and 14% of operating room teams achieved delivery within 5 minutes. Contacting the neonatal team, placing the defibrillator, resuming compressions after analysis, and endotracheal intubation all occurred more rapidly in the labor room group.Perimortem cesarean delivery performed in the labor room was significantly faster than perimortem cesarean delivery performed after moving to the operating room. Delivery within 5 minutes was challenging in either location despite optimal study conditions (eg, the manikin was light and easily moved; teams knew the scenario mandated perimortem cesarean delivery and were aware of being timed). Our findings imply that perimortem cesarean delivery during actual arrest would require more than 5 minutes and should be performed in the labor room rather than relocating to the operating room.
View details for DOI 10.1097/AOG.0b013e3182319a08
View details for Web of Science ID 000296292600017
View details for PubMedID 22015877
The Case for OBLS: A Simulation-based Obstetric Life Support Program SEMINARS IN PERINATOLOGY 2011; 35 (2): 74-79
Errors by health care professionals result in significant patient morbidity and mortality, and the labor and delivery ward is one of the highest risk areas in the hospital. Parturients today are of higher acuity than anytime previously, and maternal mortality is increasing. Obstetrical staff must therefore be familiar with emergency protocols geared to the maternal-fetal dyad. However, the medical literature suggests that obstetrical providers are not optimally trained to render care during maternal cardiopulmonary arrest. We describe the evolution of immersive learning and simulation in the Neonatal Resuscitation Program, and suggest the development of a multidisciplinary team, simulation-enhanced obstetric crisis training program (OBLS) may likewise benefit obstetrical health care professionals. OBLS would emphasize high quality basic life support, uterine displacement, use of an automatic external defibrillator, and delivery of the fetus within 5 minutes of maternal arrest should resuscitative efforts prove ineffective.
View details for DOI 10.1053/j.semperi.2011.01.006
View details for Web of Science ID 000289600200006
View details for PubMedID 21440814
Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 2010; 203 (2)
Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance.We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions.Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines.Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.
View details for DOI 10.1016/j.ajog.2010.02.022
View details for Web of Science ID 000280234500037
View details for PubMedID 20417476
Accidental intrathecal sufentanil overdose during combined spinal-epidural analgesia for labor INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA 2009; 18 (1): 78-80
A laboring woman was accidentally given 45 microg of sufentanil intrathecally in the course of combined spinal-epidural analgesia. She experienced intense pruritus and transient swallowing difficulty without respiratory depression, but still had incomplete pain relief, with delivery and episiotomy repair requiring additional analgesia. This case highlights the importance of adding local anesthetic to intrathecal opioids to facilitate effective analgesia during the second stage of labor. The contributory systems issues and multiple factors that allowed this error to occur are examined.
View details for DOI 10.1016/j.ijoa.2008.10.001
View details for Web of Science ID 000262736700017
View details for PubMedID 19111229
Use of Simulation Based Team Training for Obstetric Crises in Resident Education SIMULATION IN HEALTHCARE 2008; 3 (3): 154-160
Obstetric crises are unexpected and random. Traditionally, medical training for these acute events has included lectures combined with arbitrary clinical experiences. This educational paradigm has inherent limitations. During actual crises insufficient time exists for discussion and analysis of patient care. Our objective was to create a simulation program to fill this experiential gap.Ten L&D teams participated in high fidelity simulation training. A team consisted of two or three nurses, one anesthesia resident and one or two obstetric residents. Each team participated in two scenarios; epidural-induced hypotension followed by an amniotic fluid embolism. Each simulation was followed by a facilitated debriefing. All simulations were videotaped. Clinical performances of the obstetric residents were graded by two reviewers using the videotapes and a faculty-developed checklist. Recurrent errors were analyzed and graded using Health Failure Modes Effects Analysis. All team members completed a course evaluation.Performance deficiencies of the obstetric residents were identified by an expert team of reviewers. From this list of errors, the "most valuable lessons" requiring further focused teaching were identified and included 1) Poor communication with the pediatric team, 2) Not assuming a leadership role during the code, 3) Poor distribution of workload, and 4) Lack of proper use of low/outlet forceps. Participants reported the simulation course allowed them to learn new skills needed by teams during a crisis.Simulated obstetric crises training offers the opportunity for educators to identify specific performance deficits of their residents and the subsequent development of teaching modules to address these weaknesses.
View details for DOI 10.1097/SIH.0b013e31818187d9
View details for Web of Science ID 000207536200005
View details for PubMedID 19088659
Development and Implementation of Simulation Based Training for Obstetric Crises in Resident Education Simulation In Healthcare 2008; 3 (3): 154-160
Intraoperative forced air-warming during cesarean delivery under spinal anesthesia does not prevent maternal hypothermia ANESTHESIA AND ANALGESIA 2007; 105 (5): 1413-1419
Prewarming and intraoperative warming with forced air-warming systems prevent perioperative hypothermia and shivering in patients undergoing elective cesarean delivery with epidural anesthesia. We tested the hypothesis that intraoperative lower body forced air-warming prevents hypothermia in patients undergoing elective cesarean delivery with spinal anesthesia.Thirty healthy patients undergoing cesarean delivery with spinal anesthesia were randomly assigned to forced air-warming or control groups (identical cover applied with forced air-warming unit switched off). A blinded investigator assessed oral temperature, shivering, and thermal comfort scores at 15-min intervals until discharge from the postanesthetic care unit. Umbilical cord blood gases and Apgar scores were also measured after delivery.The maximum core temperature changes were similar in the two groups (-1.3 degrees C +/- 0.4 degrees C vs -1.3 degrees C +/- 0.3 degrees C for the forced air-warming group and control group, respectively; P = 0.8). Core hypothermia (< or =35.5 degrees C) occurred in 8 of 15 patients receiving forced air-warming and in 10 of 15 unwarmed patients (P = 0.5). The incidence and severity of shivering did not significantly differ between groups. Umbilical cord blood gases and Apgar scores were similar in both groups (P = NS).We conclude that intraoperative lower body forced air-warming does not prevent intraoperative hypothermia or shivering in women undergoing elective cesarean delivery with spinal anesthesia.
View details for DOI 10.1213/01.ane.0000286167.96410.27
View details for Web of Science ID 000250317500039
View details for PubMedID 17959975
Patient preferences for anesthesia outcomes associated with Cesarean delivery ANESTHESIA AND ANALGESIA 2005; 101 (4): 1182-1187
When deciding on neuraxial medication (e.g., spinal opioids) for cesarean delivery (CS) under regional anesthesia, anesthesiologists make treatment decisions that "trade off" relieving pain with the potential for increased risk of side effects. No previous studies have examined obstetric patients' anesthesia preferences. Researchers administered 100 written surveys to pregnant women attending our institutions' expectant parent class. We determined patients' preferences for importance of specific intraoperative and postoperative anesthesia outcomes using priority ranking and relative value scales. We also explored patients' fears, concerns, and tolerance regarding CS and analgesics. Eighty-two of 100 surveys were returned and analyzed. Pain during and after CS was the greatest concern followed by vomiting, nausea, cramping, pruritus, and shivering. Ranking and relative value scores were closely correlated (R2 = 0.7). Patients would tolerate a visual analog pain score (0-100 mm) of 56 +/- 22 before exposing their baby to the potential effects of analgesics they receive. In contrast to previous general surgical population surveys that found nausea and vomiting as primary concerns, we found pain during and after CS as parturients' most important concern. Common side effects such as pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, e.g., inclusion of spinal opioids given in adequate doses.Medical care can be improved by incorporating patients' preferences into medical decision making. We surveyed obstetric patients to determine their preferences regarding potential cesarean delivery anesthesia outcomes. Unlike general surgical patients who rate nausea and vomiting highest, parturients considered pain during and after cesarean delivery the most important concern.
View details for DOI 10.1213/01.ane.0000167774.36833.99
View details for Web of Science ID 000232115400045
View details for PubMedID 16192541
"Ultra-light" patient-controlled epidural analgesia during labor: effects of varying regimens on analgesia and physician workload INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA 2005; 14 (3): 223-229
Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for maintenance of labor analgesia. Some of these benefits may depend on the PCEA settings. This study evaluated several regimens for "ultra-light" (0.125%) PCEA with basal continuous infusion (CI) in labor with goals of minimizing physician interventions while providing good analgesia.Two hundred and twenty ASA I-II women receiving epidural analgesia during active labor (cervical dilation <5 cm) were randomly assigned in a double-blind manner to four treatment groups (n=30 in each). Analgesia was maintained with a PCEA/CI pump using bupivacaine 0.0625% + sufentanil 0.35 microg/mL. PCEA settings were: group A: CI 10 mL/h, PCEA bolus 6 mL, 8-min lockout; group B: CI 10 mL/h, PCEA bolus 12 mL, 16-min lockout; group C: CI 15 mL/h, PCEA bolus 6 mL, 8-min lockout; group D: CI 15 mL/h, PCEA bolus 12 mL, 16-min lockout.In groups A, B, C and D, 76, 77, 75 and 85% of parturients respectively, required no physician rescue boluses. Pain scores were low and maternal satisfaction was high in all groups, with minimal differences among them. Spontaneous vaginal delivery occurred in 78% of patients overall, instrumental (forceps or vacuum) delivery in 10% and cesarean section in 12%.These ultra-light PCEA regimens provided excellent analgesia with minimal physician workload and a high spontaneous delivery rate. Use of moderate to high-volume, ultra-light PCEA/CI techniques should facilitate provision of labor analgesia in busy obstetric units.
View details for DOI 10.1016/j.ijoa.2005.02.003
View details for Web of Science ID 000230915700008
View details for PubMedID 15935646
The demise of general anesthesia in obstetrics revisited: prescription for a cure INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA 2005; 14 (1): 2-4