1. The Road to Excellence
HEALTH SCIENCES SIMULATION CENTER
2. Tell me
What is your background and where do
you come from?
Hospital simulation centers
Nursing School Sim Center
University/Junior College Sim Center
Free Standing Sim Centers
HEALTH SCIENCES SIMULATION CENTER
3. Tell Me
Who has more than 10 years in
simulation?
5-10 years
2-5 years
1 year or less?
HEALTH SCIENCES SIMULATION CENTER
4. 2006 Maternal Mortality Rates
per 100,000 live births
Iceland: 0 #1 ranking in world
Sweden: 2
Austria: 4
Canada: 6
Japan: 10
United Kingdom: 13
Singapore: 15
United States: 17
HEALTH SCIENCES SIMULATION CENTER
6. Simulation Training Initiatives
PROMPT-Draycott T. MD
http://www.prompt-course.org/home
STORC-OHSU:Jeanne Marie Guise MD
MOSES: St.Bartholomew School of Nursing and
Midwifery and London Medical Simulation
Centre,multidisciplinary obstetric simulated
emergency scenarios
Obstetric Crisis Team Training. Wiser Institute.
MOES: Deering S, Rosen MA, Salas E, Simul
Healthc. 2009 Fall;4(3):166-73.
HEALTH SCIENCES SIMULATION CENTER
7. JCAHO
Recommendations:
-conduct team training in perinatal areas to
teach staff to work together and communicate
more effectively
-for high-risk events, shoulder dystocia,
emergency C-section, maternal hemorrhage and
neonatal resuscitation, conduct clinical drills to
prepare staff for when such events actually
occur and conduct debriefing to evaluate team
performance and identify area of improvement
HEALTH SCIENCES SIMULATION CENTER
8. Alta Bates
High volume
High Risk
>7000 deliveries a year
NICU
Urban Hospital Setting
HEALTH SCIENCES SIMULATION CENTER
10. Alta Bates Perinatal Group
1999: TLC program;
Teamwork
Leadership
Communication
Response to IOM report and low morale.
Year long training before bringing to the unit.
1.) Core Meeting to review each patient, q shift
2.) Debriefings of all occurrences
3.) Adoption of SBAR standard of
communication among staff members.
HEALTH SCIENCES SIMULATION CENTER
11. Alta Bates Perinatal Group
2008: Formed a Simulation Committee to
explore this methodology for staff
education.
CAPE: Center for Advanced Pediatric
Education; Stanford University. Lou
Halamek MD
Two-day training for 13 core members.
HEALTH SCIENCES SIMULATION CENTER
12. Alta Bates Perinatal Group
2008 First Five Program: initial 5’ management of critical events
2009 Samuel Merritt University’s Health Sciences Simulation
Center
Course for L&D, Neonatal Emergencies
Discussion and planning begins
2010 PROMPT shoulder dystocia training.
2010 NICU institutes NRP simulation training for all staff
members and rotating residents.
2010 FHR recognition and standardized nomenclature training
2011 In-Situ Program begins
.
HEALTH SCIENCES SIMULATION CENTER
13. Awareness
How many of you feel that your
simulation center and capabilities are
well known and integrated into the
educational system of your parent
organization or affiliated hospital
systems?
How many of you are integrated into all
your undergraduate and graduate
training programs?
HEALTH SCIENCES SIMULATION CENTER
14. First Meeting
Perinatal Plan and Design
September 13, 2009
first meeting with leadership from ABSMC.
“Design a course to train our entire staff for
L&D,Neonatal emergencies.”
Lack of definition and clarity between the two
parties regarding goals, allowed us both to
develop completely different concepts.
HEALTH SCIENCES SIMULATION CENTER
15. Perinatal Project
November 25,2009 second meeting
Plan a Pilot program for introduction of sim to
members of the L&D,NICU. Team training with
nursing, ob, anesthesia.
Three 4-hour sessions of In-Situ sims at
ABSMC. Three Scenarios.
After building departmental buy-in to sim, design
a training plan for all members of L&D,NICU,OB,
and anesthesia trained at HSSC over 10
months. 170 RNs.
HEALTH SCIENCES SIMULATION CENTER
16. What they said:
12/2/09
“The goal would be to train all the FT RNs and many of the PT
RNs. (176)
“Each 4 hour training period would train 2 teams of 3RNs / 2MDs
in 3 scenarios, scheduled as two 4-hr sessions per day, twice a
month for 8 months.” (3rn+2md) x 2/d x 2/mo x 8mo=
This would be 96 RNs and 64 MDs!!
13 member Team training 1 or 2 days
In-Situ training assistance 8hours x 6 days training a total of 12
RNs in three months.
HEALTH SCIENCES SIMULATION CENTER
17. WHAT I HEARD
December 18,2009
“I am hearing this to mean that we will use two
simulation suites here at our center,
running two sessions per day,
of four hours duration,
performing three scenarios for five learners;
3RNs/2MDs.
20 learners/day x 2d/month x 8 months= 320!
With 192 RNs and 128 MDs.”
HEALTH SCIENCES SIMULATION CENTER
18. WAS I OUT OF MY MIND!!
I JUST OFFERED TO COMMITT 10 STAFF MEMBERS AND OUR ENTIRE
WAS
FACILITY FOR 8 HOURS A DAY, TWICE A MONTH, FOR 8 MONTHS.
WE HAVE A STAFF OF 4.
KNOW YOUR LIMITATIONS.
PROMISE SMALL, DELIVER BIG.
HEALTH SCIENCES SIMULATION CENTER
19. Sanjeet Gill, HSSC south lab director; Jeanette Wong BSN,MPA,Operations
Sand
Manager; Kevin Archibald, Admin Assist; bill, Lina Gage-Kelly RN,Simulation
Coordinator; Celeste Villanueva CRNA,MS, Director of HSSC, Director of
the Program of Nurse Anesthesia Samuel Merritt University
HEALTH SCIENCES SIMULATION CENTER
20. HSSC Proposal
December 18,2009
Case One:
Team Training 13 members,2 days= $26,000
Staff Training: 320 members,8mos= $80,000
$106,000
Case Two:
Team Training = $26,000
3 Months In-Situ Assistance= $30,000
$56,000
HEALTH SCIENCES SIMULATION CENTER
21. Affiliated Discounts?
How many programs have fee schedules
that differ for their affiliated institutions vs
outside clients?
How much is that discounted rate?
10-20%?
30-40%?
50-60%?
70-80%?
HEALTH SCIENCES SIMULATION CENTER
23. Agreement
PHASE I
Program Development: 40 hrs
PHASE II
Team Training: 16 hrs
PHASE III
In-Situ Faculty assist: 48 hrs
Total hours: 104
HEALTH SCIENCES SIMULATION CENTER
24. Final Contract
Phase I
Phase I: Only Core Team (9), 40 hrs.
Location: HSSC
Course design, scenario selection, writing
scenario objectives, writing scenarios,
programming into software, operation of
software, vetting and validation, dress
rehearsal, and debrief.
.
HEALTH SCIENCES SIMULATION CENTER
31. Learning Objectives are Key
ABSMC had 3 Distinct Primary Learning Objectives
1. Learning objectives of Core Team
2. Learning objectives of Trainers in Training
3. Learning objectives for In-Situ learners
HEALTH SCIENCES SIMULATION CENTER
33. Phase I
Two Teams Emerge
Different Objectives
Labor and Delivery Team
PPH, Eclampsia, Cord Prolapse, Shoulder
Dystocia, Code C, Breech delivery.
NICU Team
Neonatal Resuscitation Protocols
HEALTH SCIENCES SIMULATION CENTER
35. 3.In-Situ Objectives
.1. State the major components of maternal-child emergency response protocols
according to the Alta Bates obstetrical and neonatal guidelines.
2. Endorse the standardized obstetrical and neonatal emergency response protocols
for Alta Bates, based on debriefing responses and post-session evaluations
3. Demonstrate the ability to perform assigned roles in a coordinate response to
per/neo-natal emergencies according to AB obstetrical and neonatal guidelines.
4. Execute the essential skill sets required to complete the roles and functions of the
assigned role, according to AB specific practices.
5. Employ/Demonstrate best practices skills of team communication, indicated by
adherence to AB defined definitions of SBAR, briefings, and call-backs
6. Engage in self-reflective learning and practices, as indicated on post-session
evaluations and feedback from debriefers.
HEALTH SCIENCES SIMULATION CENTER
37. Critical Elements
Essential actions, demonstrations, or
communications by the learners that are
required for successful completion of the
scenario.
HEALTH SCIENCES SIMULATION CENTER
38. Select the subject of scenarios
Best to use real case experience
Sentinel events
Root Cause Analysis
Near Miss data
Gives a voice to the objectives
Build scenarios backward from
objectives
HEALTH SCIENCES SIMULATION CENTER
40. Phase II
Trainers in Training
Phase II 16 hours:
Simulation Committee members (19)
Location: HSSC
Members of the Simulation Committee and
the Core team members first validate, vett,
and amend the scenarios. Then execute the
four scenarios, assume all the roles
required, instruct, mentor, and orient the
TnT’s to simulators, environment, scenarios,
and debriefing.
HEALTH SCIENCES SIMULATION CENTER
44. Phase III
Phase III:48 hours: In-Situ Simulation
Team in Training members; 6 days, 8 hours
of in-situ training for L&D RN staff.
Execution by Core Team. Manikins, video,
computers, mentoring, and debrief
assistance supplied by HSSC staff.
104 Total hours: all three Phases
HEALTH SCIENCES SIMULATION CENTER
45. In-Situ
Dress Rehearsal March 15,2011
Difficulty of In-Situ sessions:
Room not available
Short staffing calls
Distractions to staff
Inconvenient to patients
No suitable spaces
Must be flexible!!
Make it work.
HEALTH SCIENCES SIMULATION CENTER
46. In-Situ
Dress Rehearsal March 15, 2011
Advantages of In-Situ
Work with your own
environment
Systems issues revealed
Familiarity is not distraction
Increased fidelity
Abundance of resources
Administration can pop in!
HEALTH SCIENCES SIMULATION CENTER
47. Debriefing
Make it Comfortable
On the day of In-Situ dress
rehearsal no conference
space was available so the
team debriefed in the nurse
managers office.
Debriefing space was not
close-by.
Audio/Video limited
Small Spaces
Too hot
Learned for next time!!
Better to move downstairs to
conference room with space
and A/V.
HEALTH SCIENCES SIMULATION CENTER
48. Debrief the Rehearsal
Members of the entire team
review issues of realism,
sequencing, moulage,
dialogue, and fulfilling of
roles.
Note taking scribs all
debriefing elements for
summative emails and
discussions in follow-up.
HEALTH SCIENCES SIMULATION CENTER
52. “I don’t want my picture taken”
Orientation to Simulation
Safety of the environment
Not Evaluative
Discuss the power of self
reflection. That’s why we
video.
Its practice!! If you know it
why worry, if you need help
this is the place.
No harm no foul.
Celebrate mistakes.
Las Vegas rule.
Honor code.
HEALTH SCIENCES SIMULATION CENTER
53. Confederates
Confederate “patient” is mic’d
and reviewing her role with
Team members Megan and
Kristin.
Team Leaders communicate
with confederates & operator
via walkie talkies.
Consider scripting dialogue
for confederates.
Know your roles, be able to
react to learner behaviors
HEALTH SCIENCES SIMULATION CENTER
58. 6
5
4
Series 1
3
Series 2
2 Series 3
1
0
Category 1 Category 2 Category 3 Category 4
HEALTH SCIENCES SIMULATION CENTER
59. Lessons Learned
Do the hard work up front. Be methodical and realistic.
Define the Goals and work Schedule and Plan and then
backward from there to the do it again.
beginning.
Keep good debriefing notes of
Engage all members of the all meetings and rehearsals.
team.
Don’t use more fidelity than
Share the responsibilities you need.
among RNs and MDs to gain
both perspectives Confirm your space and
availability.
Identify a small group of Core
champions. Use the learning objectives to
guide debriefings.
Evaluation Tools for Teams.
Work closely with RN union. HEALTH SCIENCES SIMULATION CENTER
60. Next Steps
Twice monthly In-Situ training with HSSC
faculty assist. Then independently.
Select Simulation equipment needs
Incorporate more of the scenarios
Develop didactics and educate staff.
Distribute Team in Training members to
use fewer per session.
HEALTH SCIENCES SIMULATION CENTER
61. We got to
HANG THE MOOSEHEAD!
HEALTH SCIENCES SIMULATION CENTER
62. Perinatal Project
Building Buy-In
Where is the pain?
Bad outcomes raise insurance premiums.
Mandated by hospital Administration.
Began Discussions with med-mal insurer about
premium discounts for completion of risk
reduction course.
What would the insurer like to see in this course?
HEALTH SCIENCES SIMULATION CENTER
63. CRICO and RMF
CRICO: The Controlled Risk Insurance
Company
RMF: Risk Management Foundation
Both of Harvard Medical
Institutions, promoted sim-based team
training as a risk control strategy for OB
providers. Patterned after the successful
Anesthesia program.
Simulation in Healthcare: vol.3,No 2, 2008.
Gardner R, Raemer D, et al.
HEALTH SCIENCES SIMULATION CENTER
64. CRICO
The course was designed around Closed Claim
ob cases of Harvard affiliated Perinatal units as
the basis for simulated cases involving
teamwork and communication.
In 1 year follow up surveys, 87% said they had
experienced a critical clinical event since the
course and that various aspects of their
teamwork had significantly or somewhat
improved as a result of the course. 89% said
the CRM principles were useful and 59%
recommended repeating q 2yrs.
HEALTH SCIENCES SIMULATION CENTER
65. CRICO
The course is now a central component of
CRICO/RMF’s obstetric risk management
incentive program that provides a 10%
reduction in annual malpractice premiums.
Approximately $6000/per physician.
Too early to know if it has changed claims.
However, the same program for anesthesia
was so successful that premium incentives
were raised in 2007 to 19% for participants.
HEALTH SCIENCES SIMULATION CENTER
66. The Doctors Company
Patient Safety First: online program built
around the most common types of OB
claims, rewards physicians who
successfully implement the patient safety
steps.
Offering a 10% premium discount
HEALTH SCIENCES SIMULATION CENTER
67. Requirements
are combersome
Complete the Perinatal Bundle of Courses (Advanced Fetal Assessment and Monitoring, Managing
Shoulder Dystocia, Operative Vaginal Delivery, and SBAR+R: Structuring Communication in
Healthcare) offered online through Advanced Practice Strategies (APS). Access to these courses is
available to you through our online member login at www.thedoctors.com.
Develop written protocol for communication (SBAR+R or similar) between you and the labor and
delivery nurses to be utilized in the event that any of the following situations occur:
Nonreassuring fetal heart rates using the guidelines as outlined in the APS Advanced Fetal Assessment and
Monitoring course and any other change in the fetal tracing that you feel is reportable
Elevated systolic BP of >140 mm Hg or diastolic BP of >90 mm Hg
Vaginal bleeding
Meconium
Suspected abnormal presentation
Elevated maternal temperature >100.4 or per
hospital protocol
Other criteria occur that you have identified (e.g., rise in fetal heart rate baseline of greater than 10 bpm, more
than five variable decelerations in X minutes, etc.)
Post the communication protocol in L&D, and implement it in coordination with nursing leadership.
HEALTH SCIENCES SIMULATION CENTER
68. The Doctors Company
We are working with TDC to satisfy their
patient safety requirements for receiving
the same 10% premium discount.
Following the CRICO formula for
simulation based risk reduction.
HEALTH SCIENCES SIMULATION CENTER
70. OUTLINE
Statistics about OB safety
Perinatal Team and their commitment to excellence
Simulation and Team Training
Plan and Design of Simulation Program
Budget and Schedule
Training
Rehearsals
In-Situ Experience
HEALTH SCIENCES SIMULATION CENTER
Notes de l'éditeur
WHO Monitoring and Evaluation July 2006
The total amount spent on health care in the USA is greater than in any other countryin the world.1 Hospitalization related to pregnancy and childbirth costs some US$86billion a year; the highest hospitalization costs of any area of medicine.2 Despite this,women in the USA have a greater lifetime risk of dying of pregnancy-relatedcomplications than women in 40 other countries.Morethan a third of all women who give birth in the USA – 1.7 million women each year –experience some type of complication that has an adverse effect on their health.6
The report, "Deadly Delivery: The Maternal Health Care Crisis in the USA," notes that the lifetime risk of maternal deaths is greater in the United States than in 40 other countries, including virtually all industrialized nations.White women have a mortality rate of 9.5 per 100,000 pregnancies, the CDC said. For African-American women, that rate is 32.7 deaths per 100,000 pregnancies.
Maternal mortality rates in the state of California have nearly tripled from 1996-2006 and are 4.5 times higher than the Healthy People 2010 benchmark. No one is sure of all the reasons for this rapid and troubling increase. In the 1990s California's rates ranged from 5.6 to 10.7 deaths per 100,000 live births, which is consistent with the overall US rate. Beginning in 2000 the rate climbed to 10.9, then to 14.6 and in the last reported year it is nearly 17. Also concerning is a similar rise in the entire US rate.
HSSC staff reviewed many of the OB simulated training programs that have been reported. Some of what we found.PROMPT: practical obstetric multiprofessional trainingTimothy Draycott, Southmead Hospital,Bristol,UKSTORC: from the OHSU led by Jeanne Marie Guise MD. Using check list and training methods for standardization of care.MOSES:Dr. Della Freeth. Journal of Interprofessional Care, October 2006;20(5):552-554: from the St.Bartholomew’s School of Midwifery, and the London Simulation Center. Focusing on communication and team buildingObstetric Crisis Team Training: Wiser Institute; Based on the principles of Crisis Team Training.MOES: Anderson simulation center: Department of Defense, TEAMSTEPS format of team training…
The PROMPT (PRactical Obstetric Multi-Professional Training) course is a multi-professional training package which enables midwives, obstetricians and anaesthetists to implement a fully evaluated obstetric emergencies course within their own maternity units.The introduction of multi-professional obstetric emergency training at Southmead Hospital in 2000 was associated with: 50% reduction in Apgars < 7 in term infants (Draycott et al, BJOG 2006) 50% reduction in the incidence of HIE in term infants (Draycott et al, BJOG 2006) 70% reduction in Brachial Plexus Injuries after shoulder dystocia (Draycott et al, Obs Gyne 2008) 40% reduction in median decision-to-delivery time in cases of cord prolapse
Multidisciplinary Obstetrical Simulated Emergency Scenarios; J Contin Educ Health Prof. 2009 Spring;29(2):98-104.
Article: Sim Healthcare 4:77-83,2009Bethany Robertson, DNP;Michael DeVita MD,FACP. Wiser Institute, Pittsburg,Pa.Resulted in increased confidence in handling obstetric emergencies, improved individual and team performance, and task completion.
MOES: Mobile Obstetric Emergencies Simulator system: Developed at Madigan Army Medical Center, Fort Lewis, Washington.by LTC Shad Deering.MOES has now been licensed to Gaumard Medical, largest obstetric simulation company. Two Important feathres:1) mobility to afford regular practice opportunities on the actual L&D ward, and 2) an emphasis on teamwork as well as technical skills. Targets these Ob emergencies: breech vaginal delivery, eclamptic seizure, postpartum hemorrhage, operative vaginal delivery, umbilical cord prolapse, shoulder dystocia, and neonatal resuscitation.
All received a multiple-choice pre-training and pre-testing questionnaire. After 1 month all teams underwent performance testing as a l&d drill. Videotaped and scored by a blinded reviewer. Pre-training/pre- testing questionnaire scores. Performance testing in the l&d drills showed statistically significant higher scores for the sim group for both shoulder dystocia and eclampsia management.
Sentinel Event ALERT Issue 30-July 21, 2004.
Give more data.
9 members: Obs, Neonatologists, Anesthesiologist, Perinatalogist, RN managerBegan a Quality Improvement initiative within their department Women’s and Infants Services.
19 members of the committee: L&D Rns, NICU nurses, Perinatologists, neonatologists, anesthesia, and OB .Attended two day training at CAPE, wrote scenarios and returned home.While thinking of what simulation equipment to purchase, the committee learned about the presence of a State of the Art, simulation center just steps away.
Steady progression of quality improvement initiatives designed around team training, and communication. Incorporating a variety of learning modalities into the clinical environment.
Samuel Merritt University’s Health Sciences Simulation Center sits on the Sutter Health Hospital campus and was virtually unknown to that system administration or institutional educators.
The Simulation training would be part of a SKILLS DAY FOR NURSES, half a day spent simulating, the other half doing task traiing.Well it was clear to me that they didn’t know what they wanted. So I’ll give them what I want! And I wanted BIG and Complicated..
Direct quote from my follow up email.
Thank heavens this wasn’t accepted because we could not have delivered a quality program at that time.
Two suggestions: Case One with all the bells and whistles would have trained their Sim Team at the Center and all of their staff in 8 mos. Case Two: HSSC would do a two day simulation training to their Sim Team and then provide 6, 8 hour days of assistance while the ABSMC Sim Team began doing In-Situ training.
Used the Laerdal educational format to orient, educate, and instruct the operations of the SimNewB manikin and its graphic user interface. Tought fundamental programming skills, and had Core Team plan, design, write and program their scenarios.
Establishing written timelines was essential to progress. It stated the goals of each engagement, the time, location, person(s) responsible for execution and the dates. Kept the Core Team on task and guided their work offsite.
Different needs, and focus for training and simulation. So we separated them and did unique educational sessions for each.
These became the Primary Learning Objectives for all In-Situ Simulation Sessions.
Three page template
Core came to realize that there is a great deal of preparation that is necessary before the cameras start to roll, and Team members need to perform in their assigned roles.
The full team Simulation Committee now comes to HSSC to participate in the validation and vetting of the scenarios written by the Core Team. Goes through the scenario template for each scenario with a different set of eyes and makes suggestions and changes get made. Then the Core Team assumes the roles necessary to execute a simulation session and uses Team in Training members as confederates, learners, operators, session coordinators. Debrief after scenarios again.
We lost our L&D operating room that was adjoining a conference room. Instead, we used a L&D room on the unit for simulations and used the Nurse Managers office in another hallway. This meant that the wireless audio video system had to be hardwired and no longer entirely mobile. This meant the computer operators now had to be present in the simulation room during the scenarios execution.
Issue of available space is always a concern with In-Situ simulation.
With each practice of the scenarios, THE TEAM gets smoother and smoother in execution.
Preparation and Parallel Processes require coordination of Team Members to set up simulation equipment, simulation room, confederates, A/V equipment, cameras and computers. Also time to present Philosophy of Simulation, Safe Environment, Las Vegas Rule, and orient to the room.
There was a Morning Session and an Afternoon Session: Each session had 8 learners. Each PPH scenario had 4 learners: Primary RN, Resource RN 1&2, Charge RN.The scenario was performed twice and debriefed after each. Second scenario: Precipitous Delivery requiring PPV was brief, usually 3-4 minutes. Teams of 2 RNs in each scenario. Performed 4 times quickly, then debriefed them all together. Afternoon session repeated same sequence.
Roles of Team Leader, Session Coordinator, Operator, and Debriefers were rotated among the Team in Training members.
Using an open L&D room required staging to occur in the hallway. Not the best location. Patients and family nearby.
Once the action started, the learners forgot about the Team members in the room as operators and evaluators.
Team Leaders and Coordinators are constantly reviewing timelines and schedule to stay on time. Most of the scenarios run 10-12 minutes. Precipitous Delivery went 3minutes!!
Debriefings can be the time for teaching around Primary and Secondary Learning Objectives.
N
All physicians in a group must complete the program in order for them all to receive the discount.