PRONTO: Obstetric and Neonatal Emergency Simulation in Mexico Improves Patient Outcomes, Provider Knowledge, Team Coordination, and Identifies Latent Systems Errors
Authors: Walker Dilys , Cohen Susanna , Fritz Jimena , Olvera Marisela , Zelek Sarah , Cowan Jessica Greenberg , Gonzalez Dolores , Dettinger Julia C. , Fahey Jenifer , Lamadrid Hector 
Published: October 2014

PurposeTo assess the impact of an emergency obstetric and neonatal simulation‐based team training program (PRONTO) on process indicators and maternal and neonatal outcomes.Research QuestionsDoes PRONTO training improve participating providers’ obstetric and neonatal emergency knowledge, self‐efficacy, and goal achievement? Do public hospitals in Mexico where providers receive PRONTO training have different maternal and neonatal outcomes than control hospitals?SignificanceStudies in resource‐stable countries have found improved patient outcomes following participation in simulation team training. However, limited‐resource countries, like Mexico, rarely have access to such trainings given the high cost of simulation. Acknowledging the potential for low‐tech, highly‐realistic simulation in resource‐limited settings, PRONTO was piloted in 2009. Its impact on patient outcomes has yet to be evaluated.MethodsWe implemented a matched cluster, quasi‐randomized trial of PRONTO training in 24 public hospitals in 3 Mexican states from 2010 to 2012. Intervention hospitals (n = 12) had selected providers (n = 450) participate in PRONTO training. Providers were trained in 2 modules, 2 to 3 months apart focusing on the topics of neonatal resuscitation, obstetric hemorrhage, preeclampsia/eclampsia, shoulder dystocia, teamwork, and communication using obstetric emergency simulations, guided debriefings, skill stations, and team‐building exercises. Data collection included baseline facility inventory and chart review, pre‐post intervention individual participant testing, and 12 months of follow‐up, chart review, and birth observations. Pre‐post process indicators were analyzed using linear regression. Outcome data were analyzed using negative binomial regression with a difference‐in‐difference approach for the 3 months prior to data collection at 4, 8, and 12 months follow‐up non‐cumulatively.ResultsFollowing PRONTO training, knowledge and self‐efficacy for physicians and nurses (P<.001‐.009) significantly improved for all tested topics. Teamwork scores improved during Module I and were maintained through Module II. Participating hospital teams achieved an average of 6 strategic planning goals per hospital, more than 50% of the goals that they set for themselves during the training. The intervention did not significantly impact rates of hysterectomy, obstetric hemorrhage, preeclampsia, or eclampsia. Impact estimations showed a 44% decrease in hospital‐based neonatal mortality rates at 8 months postintervention (incidence rate ratio [IRR], 0.56; 95% confidence interval [CI], 0.13–0.64).There was a significant reduction in the rate of cesareans at 4 months (IRR, 0.83; 95% CI, 0.40–0.29), 8 months (IRR, 0.77; 95% CI, 0.10–0.35), and 12 months (IRR, 0.79; 95% CI, 0.8–0.32) follow‐up.DiscussionMaking simulation accessible globally has the potential to save the lives of mothers and newborns, particularly in the most resource‐limited settings. Highly realistic, low‐tech simulation coupled with team training can improve provider knowledge, self‐efficacy, and teamwork, in addition to neonatal mortality and cesarean rates. More research is needed to assess the program's impact on patient‐level measures of morbidity and mortality.