# Presentation: 172647

## Emergency Delivery Simulations:  How to Develop Effective Teamwork

- Michele R. Lauria MD, MS
- Associate Professor OB/GYN
- Medical Director NNEPQIN

## Emergency Deliveries:Creating Excellence Out of Chaos

## Objectives

**How process mapping improves clinical care**
**Establish the rate limiting steps in the processes in emergency cesarean deliveries**
**Identify underutilized local resources that could improve patient care**
**Describe how to initiate and learn from simulation experiences**
**Develop tools to review and learn from emergency cesarean deliveries and simulation experiences**

## Patient Safety & Simulation

- Ideas from Jeffrey B. Cooper, PhD
- Harvard medical School
- Director, Center for Medical Simulation

## Medical Errors

**Eighth leading cause of death USA**
**Annual cost $29 billion**
**Systems problems**
**Just like other industries**
**Columbia disaster**
**Culture:  show it is not safe**
**Don’t’ recognize problems until the disaster**

## Quality

- What the medical errors experts say:
- No one should be hurt by care process
- Can’t have quality unless safety is first
- Model:  High reliability organizational culture
- High risk fields
- Minimal accidents
- Ie:  Airlines, explosives, aircraft carrier
- Can we expand errors to include failure to follow recognized guidelines?
- Errors folks say no....
- Errors are rare events, quality issues are common

## What is an Accident

- The Normal Accident
- Unpredictable
- Highly Complex
- Highly Coupled/Interactive
- More than one unexpected error
- Safety systems bypassed
- Safety systems create error through chaos
- Poor Communication
- Knowledge Deficit

## Simulation

- Improve knowledge base
- Management of rare events
- Tracheostomy traning in anesthesia
- Early training of common problems
- Shoulder dystocia drills
- Realistic & expensive
- Boston site $900/MD/day
- Ie airlines, aerospace
- Team Training
- ? How realistic... need elements
- Fun is key
- Sports teams
- Process mapping
- Microsystems testing

## Microsystem problems

- System weaknesses:  procedures insensitive to how things really happen
- Latent failures: problems lurking throughout the care process
- Lack of teamwork:
- Poor communication
- Focus on hierarchy instead of expertise
- Failure to appreciate the limits of human performance
- Cultures that blame people instead of system
- Don't learn about their problems
- For fear of exposure, don't discuss problems

## 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 thing is happening in OB
- Malpractice premiums increase

## Anesthesia Solution

- President of the ASA made patient safety the 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
- Standards for minimal monitoring
- Simple and easy to accept
- Start small, build incrementally.
- Studied closed claims
- Simulation and crisis management

## Anesthesia Today

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

## Elements of an HRO

- Safety #1 priority
- Safety trumps production always
- 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

## Microsystem Lessons

- Standardization has benefits
- OB is further than most fields in medicine
- Excessive procedure-alization can be counterproductive
- Flexibility to meet individual patient needs
- Teams and microsystems are critical
- Real teams train
- Performance degrades when training stops
- No one can tell me frequency of training
- Q 18 mos for skills

## Creating Team Work

## M&M Conferences/Debriefings

- Multidisciplinary
- All staffing levels
- Open discussion of error
- Or less than ideal perofrmance
- “Near Misses”
- Supportive environment
- No individual blame
- Method of closing the loop

## Near Miss Box

- Box to report events
- What almost happened
- What prevented it from happening
- System fix
- Reward ideas and ingenuity
- Unit Newsletter

## Simulation:  Two Processes

- NNEPQIN identifies ED critical area
- Feb 9 process mapping
- March Simulation drills, document refinement
- DHMC with VOX
- Collaborative team training
- 8 participating hospitals
- Create the perfect video
- Started 10/03

## Eight  Drills Completed Using Simulator

- Steps:
- Instructor Creates a Scenario
- Pre- Meeting to Discuss Areas for improvement from last drill
- Run the Drill, Video Taping all Action
*	**Required Process Mapping*

## Drills Continued

- 4. Debrief Immediately After Drill
- Replay video tape to Team
- Discuss what we learned i.e.
- Went Well
- Went Poorly
- What to practice
- Barriers
- Set Goals for next Drill
*Everyone Participates*

**Notes:**
Surveillance: describe how you discovered the problem...routine chart audit, voluntarily reported adverse event or near miss, proactive hazard screening, etc...)

## Creating Team Work

- Defined roles
- Everyone understands other person’s role
- Speak Back
- Questioning
- Thinking the problem out loud
- Flat communication structure

## Challenges

- STAFFING FACTORS:
- Difficult to assemble the same team on a routine basis
- Team members roles and responsibilities were confusing
- ENVIRONMENT/TECHNICAL:
- Unable to have bio-med tech support after 3 pm
- Problems with the STAT c-section paging system
- BEHAVIOR FACTORS:
- Letting go of what has been done in the past
- PATIENT FACTORS:
- Identifying the maternal/fetal factors that result in urgent or STAT c-sections

## Countermeasures

- Invited staff who were dissatisfied with the present process
- Held drills same time and day of the week
- Viewed videotaped drill, which brought realization to team members that team performance was not optimal
- Collaborated with key person experienced in teaching Team Performance
-  Set time line for project

## Lessons Learned

- Pagers frequently didn’t work
- “Painted” Stat Pagers
- Removed “forwarding” capabilities
- Established Daily Testing Stat Paging System
- Reduced number of folks doing transport
- Disconnecting IV’s
- Reassigned MD tasks
- Critical communicators at scrub sink
- Ask permission to leave room
- OR Grease Board:  Meds, Allergies, Fetuses, Mec, GA, Indication

## Principles for Drills

- Fun
- Create Tension
- Asthmatic can’t be intubated, spinal not working, heart rate going down
- Low Tech
- Dummy Chart
- Trainer
- Observers

## Drill One

## Sometime Months Later

## What is our Real Purpose

- Create demonstration video
- Train new staff
- Test the system
- Practice for rare events
- Create a set of principles
- Become ingrained
- Permit flexible responses

## The Normal Accident

- Highly Coupled Systems
- Not a linear production
- Transform a product
- Pregnant woman no longer is
- Complex Systems
- Interactions unpredictable
- Setting and Personnel Interact Unpredictably
- Never just one error or person

## Swiss Cheese

## NNEPQIN

- Ordinary people collaborating
- Emergency Cesarean Section Tool Kit
- Simulation Planning Guide
- Global Process Map
- Detailed Process Map
- Solutions for common problems
- Simulation task evaluation form
- Drill debriefing form
- Emergency delivery debriefing form
- Patient/Family
- Staff

## NNEPQIN

- Roving Simulator
- Common Trainer
- Share solutions, lessons learned
- Saturdays
- After 2 weeks of having simulator locally
- Provide regional data analysis
- QA protected
- ? IRB approval

## Materials Available @ NNEOB.org

## Global Process Map

- Pt potential need for stat **C/S**

- Consent for possible **C/S**

- Notify teams of possibility

- Prepare for possibility

- Patient delivers

- Take everyone off alert

- Resuscitate baby

- Communicate with family

- Finish **C/S**
- Count
- Change gloves
- Antibiotic prophylaxis
- X-ray if no pre-op count done
- If GET, is there a risk for pneumonia?

- Debrief Unit

- Debrief Patient & Family