# Presentation: 095284

## Optimizing Care Through Simulations and Structured Communication 

- Michele R. Lauria, MD, MS
- Dartmouth Hitchcock Medical Center
- Northern New England Perinatal Quality Improvement Network

## Objectives

- Understand the link between simulation and continuous quality improvement/error reduction
- Abstract experience in other industries and apply it to Obstetrics
- Implement a program of emergency simulations.
- Describe the benefits and technique of SBAR

## Obstetrics is a High Risk Industry

**Notes:**
None of us would be here if it wasn’t
Most of us tend to like the unpredictablil
From my lsat conference... you all fly biplanes in Alaska, go to Afghanastan
However, we all want good outcomes... it’s the ride to getting there that we cherish. 

## We all want good outcomes.It is the ride we take to getting there that we cherish.

- The descent into the pit when catastrophe is happening is what we need to avoid.

## High Risk Industries

- Transformation of Materials
- Complex processes
- Potential for Devastation
- Examples
- Nuclear Power
- Chemical Processing
- Aviation

## Birth?????

- Life in water to life in air
- Parasitism to “Independence”
- Massive vascular changes
- Three specialties
- Many levels of providers

## Industrial Accidents

- The Normal Accident 1973
- Most accidents are due to inherent flaws in the System
- Many mistakes compounded
- Each combination is unique
- Columbia disaster
- Culture:  show it is not safe
- Failure rate of 1:1000
- At least 10 failures
- Failed to recognize problem until  disaster

## Swiss Cheese

## Industrial Accidents:  Culture of Blame

- Focus:  Individual
- Hides problems
- Hierarchy valued; not expertise
- Prevents open discussion and learning
- Promotes fear

## Industrial Accidents: Culture of Safety

- Focus:
- Processes
- Environment
- Collaboration among all levels of employees
- Collaboration with other companies

## Elements of an HRO(Highly Reliable Organization)

- #1 priority:  Safety
- Safety >> production
- Pre-occupation with failure
- Commitment to resilience
- Practice is routine
- Deference to expertise, not hierarchy
- Sensitivity to day-to-day operations
- Reliance on team work

## Slide 12

**Notes:**
This is funny and you can comment that if medical errors has made the comics – it must be a problem.

## Medical Errors:  IOM

- 8th leading cause of death in US
- Annual cost: $29 billion
- Error:  A failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
- Adverse Event:  a complication of treatment, many ... not preventable

## Lucian Leape MD

- Everyone makes errors everyday
- No one makes an error on purpose
- An error is not misconduct
- We make errors for a reason

## Given an organization of fallible human beings, the issue is not why does an error occur, but rather, why wasn’t the error corrected....When an unexpected event occurs, we first have to notice it, then we have to make sense of it, and finally we have to do something about it.

- <date/time>

- Given an organization of fallible human beings, the issue is not why does an error occur, but rather, why wasn’t the error corrected....When an unexpected event occurs, we first have to *notice* it, then we have to *make sense* of it, and finally we have to *do something* about it.

*Karl Weick*

## Why Do Errors Occur?

- Personnel Issues
- Interruptions
- Fatigue
- Multi-tasking
- Poor communication

## Why Do Errors Occur?

- Environment Limitations
- Failure to follow-up (labs, testing)
- Challenges to follow-up (notification)
- Call bells in difficult places
- Narrow, low doors
- Changes in stocking
- Incomplete hand-offs
- Ineffective communication
- Failure to adhere to protocols

**Notes:**
Michele – the first line used to read:  Environment not conducive to good care – I changed it to be 

## Slide 18

## A Lesson from Anesthesia

- 1950-70's
- 1+mortalities/10,000 GET
- 1970's
- first studies of medical error and human factors
- 1980's
- Malpractice crisis escalates
- Media coverage of deaths and brain damage
- Same trend in OB
- Malpractice premiums increase

## Anesthesia Solution

- ASA president makes patient safety  primary theme and goal
- Ensure no one is hurt
- Free safety newsletter to everyone
- Funded many safety projects and research
- Partnered with industry
- Pulse oximetry
- End tidal C02

## Anesthesia Solution

- Standards for minimal monitoring
- Simple, easy to accept
- Start small, build incrementally.
- Studied closed claims
- Simulation and crisis management

## Anesthesia Today

- Risk of GET in healthy individuals <1/100,00
- Premiums decreased
- 1987 $35,000
- 2001 $9,000
- Involve patients and families
- Disclose error

## Obstetrics

- High Risk Industry
- Birth is a transforming process
- Interaction of multiple disciplines
- Potential for devastating consequences
- Escalating insurance
- Usually, everything goes well
- Disasters are typified by multiple failures
- Time can be critical

**Notes:**
I deleted the line “team.”  after “interaction of multiple disciplines.”

- When Do ***YOU*** Want to Discover Errors?
- 3 am during your crash for FHR of 40?
- 9 am with your favorite LNA pretending to be pregnant?

## JACHO Sentinel Event NewsletterJuly 2004

- 71 cases of perinatal death or permanent disability reported to Joint Commission
- Of those 71 cases
- 61 resulted in infant death
- 10 cases involved permanent disability.
- Communication errors were most common
- United Kingdom Confidential Inquiry

## Joint Commission Recommendations

- Conduct *team training* in perinatal areas to teach staff to work together and communicate more effectively.
- For high-risk events, such as shoulder dystocia, emergency Cesarean delivery, maternal hemorrhage and neonatal resuscitation, conduct *clinical drills* to help staff prepare for when such events actually occur, and conduct *debriefings* to evaluate team performance and *identify areas for improvement.*

## ACGME Outcomes

**Residents are required to:**
- “demonstrate ***interpersonal and communication skills*** that result in effective information exchange and teaming with patients ... and professional associates.”*
*  **	** *** ACGME General Competencies, Version 1.3 (9/28/99) www.acgme.org*

## Healthcare Team

- Common purpose
- Set of performance goals
- Standard to which they hold themselves mutually accountable

- Healthcare **Team**

## Characteristics of Effective Teams

- Briefings
- Clear roles, understood by team
- Appropriate assertion
- Communication
- Situational awareness
- Debriefing/learning
- Leadership

## Medical Team Training

*Providing safe and efficient patient care *
*requires teamwork!*
- However team members...
- Are rarely trained together
- Come from separate disciplines
- Have diverse educational backgrounds

## Simulation

- Simulation is an integral part of team training used by other industries:
- Commercial aviation
- Nuclear power
- Military
- These industries have intrinsic hazards and complexity, but have very low failure rates

## Simulation

- Improves knowledge base
- Management of rare events
- Tracheostomy training in anesthesia
- Early training of common problems
- Shoulder dystocia drills
- Team Training
- Sports teams
- Fun is key
- Process mapping
- Microsystems testing

## Types of Team Training

- Simulation Center
- Realistic & expensive
- Ex. airlines, aerospace
- Boston Sim Center $1000/person/day
- In-situ
- Less realistic
- Allows evaluation of processes as they truly happen
- Evaluates the environment
- Minimal costs: personnel and perishable equipment
- Learn other roles
- Value is questionable

## Objectives of Simulation

- Learners can practice the following:
- Situational Awareness
- Communication
- SBAR
- Assertiveness
- Teamwork
- Requires practice
- Train to point of over-learning
- “Full” simulations hone teamwork skills under conditions of ambiguity, time pressure, stress
- Training is not a one-time event
- Frequency is not well defined
- Degredation at 18 months described

## Stat Cesarean Section

- Team Experience
- Team leader
- Coordination
- Communication
- Physical Effort
- Time is critical
- Safety

## NNEPQIN

- Consortium of hospitals NH, VT, NY
- Community hospitals with ~250 del/year
- Tertiary care medical centers
- Started with VBAC
- Risk stratified guidelines
- “Immediately Available”
- ACOG award
- Emergency Cesarean Delivery
- How good are you?

## Site Survey

- 9 responded
- 8 have emergency protocols
- 4 have defined roles
- 7 have stat trays
- 4 have unit drills
- 2 have structured debriefing
- Some track outcomes
- No one tracks times prospectively

## Stat Trays

- Large variation in size
- Common denominators
- Variation in who starts c/s
- OR team
- OB team for entire case
- OB team until OR team arrives
- What is our goal?
- Not to confuse the scrub
- Get baby out!

## Chart Review

- Remarkable stories of fast times
- Community hospital 28 minutes from arrival to delivery with FHR of 60.
- Times of under 10 minutes
- Huge variation in times
- Range for c/s under general 9-39 minutes
- Unclear why
- Some sad outcomes
- Neonatal demises
- 10 minute Apgars of under 3

## NNEPQIN Emergency C/S

*In-situ* Simulation
- Simulation planning guide
- Task evaluation tool
- Debriefing form
- Global Process map
- Detailed process map
- Stat cesarean section tray
- 360o stat c/s feedback tool

## Alice Peck Day Memorial Hospital

- Small Community Hospital
- 250 Deliveries a year
- “Low Risk” OB
- No “in house” operating room or anesthesia personnel

- Mooney et al 2007

## Phase 1- Pathway

- Mapped out _*all*_ the steps involved in a routine Cesarean Section
- “Tell me what you really do, not what you are supposed to do”

## Slide 44

## Phase 2 - “STAT” pathway

- Communication
- Standardized terminology
- Standardized data collection tool
- Synchronized hospital clocks

## Phase 3 – Training/Practice

- Empowered Certified Nurse Midwives and birthing center nurses
- Cross trained birthing center nurses
- Operating Room “Skills Day”

## APD Experience

## <footer>

- <date/time>

## DHMC

- ~1100 deliveries per year
- ~40% high risk
- Single provider group
- 11 OB MD (4 MFM)
- 6 CNM
- 16 residents (no resident clinic)
- Single unit:  ante, intra, post
- Nurses must have many skills
- OB nurses scrub the c/s

## Goals for Team Performance Drills

- Create a simulated, reproducible event representing an emergency delivery
- Practice the event until
- Team performance is optimized
- Response is “Gold Standard”
- Processes of providing care
- Team communication skills
- “Gold Standard” -- expected practice for all staff members caring for OB patients.

## DHMC Enters Simulation

- Goal: Improve patient care
- Identify barriers to good care
- Structural:  i.e. paging systems
- Communication
- Cultural
- Experiential Education
- Important with new nurses
- Teach Team Behaviors
- Encourage SBAR
- Bring patient safety to the forefront

## What We Did

- Four drill sessions (2-3 hours each) on labor floor
- Video taping
- Debriefed after 1 or 2 back-to-back drills
- Replay video tape to team
-  Discuss what we learned i.e.
- What went well and didn’t with sim or real life
- Barriers to a good sim or providing care
- How to improve the process

## Lessons Learned

- Very useful to do an unrehearsed first video.
- Great reference to refer to
- Use folks who can laugh at themselves
- Use folks who think they do it well
- Use folks who want to be involved in the improvement process

## 11 minutes decision to incision

## Lessons Learned

***Communication is Key***
- Stat pager system
- Anesthesia and OB attending pagers failed
- Red code button in rooms
- 5 different names for the buttons
- Half the staff didn’t know purpose
- ICN and Anesthesia Teams
- Received incorrect information
- Lacked needed tools or support
- Anesthesia especially.
- No identified leader

- Recognized by members
- Not necessarily ***Clinical*** decision-maker
- Skilled in leadership strategies
- Resource Management
- Conflict Resolution
- Skilled in teamwork strategies
- Communication
- Mutual Support
- Situation Monitoring

- Team Leader Characteristics

## Delegation of Resources

***Delegation*** –
-   means of managing resources whereby leaders allocate
- material resources to teams
- human resources to specific tasks

## Changes

- Disconnect IV’s prior to transport
- Raise bed to high position prior to transport
- Tape Bicitra to pillow in OR
- Renaming of nurses
- Top nurse:  primary pt nurse, stays at head, helps anesthesia, calms patient
- Bottom nurse:  foley, prep, circulates
- Circulator:  often team leader, charge nurse
- MD’s don’t transport
- Communicate with pedi and anesthesia
- RNs and LNAs instructed in anesthesia area
- Scrub/charge nurse is team leader

## Identified a need to improve communication

## Slide 60

## Characteristics of Effective Teams

**How and Why Teams Fail**
- Verbal communication may fail when:
- We do not clearly identify the intended recipient of our communication and gain their attention.
- We do not explicitly verify that our message was received and understood.

- <date/time>

## Characteristics of Effective Teams

- 	Verbal communication fails when:
- We know something is wrong but do not clearly and explicitly communicate the problem
- 	e.g., we hint
- We do not assert an issue or problem until it is resolved
- We become task-fixated or overloaded and fail to articulate our thoughts, expectations, and intentions to
-   team members

## Challenges with Assertion

- Role-based hierarchy/authority gradient
- Who may speak up to whom
- Difficult to “hear” an alternative perspective
- I intubated the baby.  Oxygen saturation is fine so then everything is fine!”
- Fear of appearing stupid
- Feel something is awry but afraid that the concern is due to lack of knowledge and stating concern will reveal your own inadequacies.

## Team Communication Ground-Rules

- Any team member can discuss information
- Engage in interactive dialogue
- Be respectful and inclusive

## Team Communication Ground-Rules

- Be clear and concise
-  specific language
-  efficient delivery
-  use standard terminology when possible
- Clarify understanding
-  offer alternative perspective
-  share additional information
-  ask for clarification

## How We Talk Reflects Training

- Nurses:  Big picture, narrative, don’t diagnose, lead to decision
- Difference between what they are saying and what they want to convey.
- Doctors:  Headlines, very concise, very diagnostic.
- If authoritarian can create risk by not permitting a full story, not inviting participation
- 							M Leonard

## Tool For Communication:  SBAR

- 	SBAR – concise approach to verbal communication among team members.
_**S**_ituation: ** **State what’s happening, i.e.  chief concern, critical change...
_**B**_ackground: What preceded this situation, i.e. lab trends, vital signs
_**A**_ssessment:** **What do you think is going on and what leads you to think so?
_**R**_ecommendation:**  **What action do you recommend?  What do you think the other party should do?

## SBAR

*“**Identify the “R” in the following communication”*
- I think there is a possibility of uterine rupture.  The patient’s vital signs are ..........
- She’s had a VBAC
- Something is not right
- I think a C-section is needed

## Closed-Loop Communication

- Read-back
- Say-back
- “Sterile” communication environment

## Conclusion

- OB is an industry
- High Risk
- Transformational
- Complex
- Multiple teams
- Traditional Silo Training
- Other High Risk Industries have become High Reliability Industries

## Conclusion

- Tools to changing your industry
- Focus on systems
- Eliminate a culture of blame
- Use Structure Communicaiton
- SBAR
- Closed loop communication
- In-situ simulations
- Recognize everyone’s contribution
- Have Fun!!!

## Questions?

- WWW.NNEPQIN.ORG

## Time Out

**T**iming
**G**estational Age
**I**ndication
**F**etal issues
**M**edications in Labor
**A**llergies
**M**aternal Morbidity
**M**econium

## NNEPQIN History

- NNEPQIN tools created as DHMC tools created.
- Borrowed heavily from each other
- DHMC “lab” to try simulations
- Large auditorium with 60 providers with simulation
- NNEPQIN provided large scale feedback
- Emergency delivery guidelines particularly

## Global Process Overview

- Applicable in all settings
- Helps identify where work is needed
- Brings all parts of the team up to speed

## Detailed Process Outline

- Framework of global overview
- Multiple solutions to problem areas
- Highlights issues to needing attention
- No single right way
- Can create the format for a unit protocol

## Simulation Equipment/Planning Guide

- List of equipment
- List of personnel
- Time table
- Extremely useful!!!!

## Simulation Task Evaluation Tool

- Evaluates major areas
- Why events do go right
- Is communication working
- Very easy

## Simulation Debriefing Tool

- Objective feedback to improve simulation
- Gets folks accustomed to evaluation
- Level field

## Emergency Cesarean Delivery Outcomes Tracking Tool

- 360o evaluation
- Nursing
- Providers
- Patient
- Family
- Unit leader responsible
- Makes each event a learning opportunity
- Standardized responses to see trends over time
- Open-ended questions

## Expediting Delivery

- Early Notification
- Any suspicious/pathologic or “at risk” tracing
- Notify:  Anesthesia, Pediatrics, OR Team
- Ready to deliver within 30 minutes
- Expeditious measures
- 18 gauge IV that works
- Foley catheter
- Pre-hydrate
- Shave
- OR ready to be opened
- Isolette prepared:  GA appropriate
- Oxygen, laryngoscope, ETT tube
- Delee suction

## Communication

- T
- G
- I
- F
- M
- A
- M
- M

## Communication

- Time Frame
**Stat Cesarean Delivery**
- Impending fetal or maternal death
- Minimize time from decision to delivery
**Urgent Cesarean Delivery**
- Deteriorating maternal or fetal condition
- No imminent risk of fetal/maternal compromise
- Indications with wide variation in timeliness
- Safety of patient & providers always considered
- Examples:  arrest disorders, NRFHR
**Unscheduled Non-Urgent Cesarean Delivery**
- Includes c/s for malpresentation in early labor, refused TOL
**Scheduled Cesarean Delivery**