Team training in emergency obstetrics Joost van de Ven WKZ September 16th 2009

TOSTI Training Obstetrische Spoed Teams Interventie – studie Reducing errors in health care: cost-effectiveness of multidisciplinary team training in obstetric emergencies

Contents Background Team training TOSTI-trial study protocol

Background Many avoidable deaths in hospitals because care team is not well attuned Training in emergency situations generally on individual basis In practice treatment by team composed of various disciplines

Team training

Team training Emergency situations: “Crew Resource Management” derived from aviation industry Giving team training to clinical teams leads to improvements in: dealing with fatigue team building communication recognising dangerous situation decision making providing feedback

Team training medical centre Advantages promotes cooperation and reduces number of communication errors possibility to train rare emergency scenarios acceptance of team training results in culture with more attention to patient safety Disadvantages costs

TOSTI Aim: evaluate (cost) effectiveness of multidisciplinary team training in a medical simulation centre to reduce the number of medical errors in obstetric emergency situations

TOSTI Multicente randomized study Obstetric departments in the Netherlands (teaching and non-teaching) Randomly assigned to multidisciplinary team training control arm Exclusion: already multidisciplinary team training

TOSTI High-fidelity simulators in MedSim© (Medical Education and Simulation Centre) Simulation setting that resembles reality (delivery room) Multidisciplinary team training gynaecologist midwife educationalist

TOSTI One day “own” team One hospital trained <1 month gynaecologist resident midwife nurse (anaesthesiologist/ paediatrician) One hospital trained <1 month

TOSTI Scenarios Briefing – simulation - debriefing shoulder dystocia severe post partum haemorrhage eclampsia twin birth delivery breech delivery amniotic fluid embolism Briefing – simulation - debriefing

TOSTI Power analysis Reduction in perinatal asphyxia of 40% (from 1% to 0.6%) Two groups of 8.000 deliveries Average 1.000 annual deliveries Follow-up 1 year: 16-20 hospitals necessary Follow-up 6 months: 32-40 hospitals Preference: at least 20 participating hospitals, follow-up 1 year

TOSTI Intention-to-treat analysis Stratification hospitals teaching non-teaching

TOSTI Primary outcomes number of obstetric complications throughout the first year after the intervention Obtained from regular obstetrics recordings or separate registration (CRF)

TOSTI Primary outcomes: asfyxia (AS 5 min. <6 and/or pHa <7.05) shoulder dystocia (lesion brachial plexus, clavicle fracture) eclampsia HIE (Hypoxic Ischemic Encephalopathy) severe post partum haemorrhage (blood transfusion >4PC’s, embolisation, hysterectomy) amniotic fluid embolism

TOSTI Secondary outcomes human factors team work patient safety

TOSTI Economic analysis Many hospitals <1000 annual deliveries Cost-effective to train in medical simulation centre? well trained personnel high fidelity simulators well defined training programmes

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