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

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

3. Contents
Background
Team training
TOSTI-trial
study protocol

4. 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

5. Team training

6. 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

7. 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

8. 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

9. 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

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

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

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

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

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

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

16. 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

17. TOSTI
Secondary outcomes
human factors
team work
patient safety

18. 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

19. Thank you for your attention!