Royal College of Surgeons and South West Professional Affair irs Board Trainee Event Mr Dimitrios Siassakos Consultant Senior Lecturer in Obstetrics Director of Research, Academic Centre for Women’s Health, Southmead Hospital Lead for Obstetric Undergraduate Education, University of Bristol Regional Lead for Obstetric Simulation, Severn & Peninsula Academic Centre for Women’s Health University of Bristol
Declaration of Interests • Executive BJOG Editor • Member, PROMPT Maternity Foundation • Co-chair, Scientific Committee, International Stillbirth Alliance • Grants from NIHR, Ferring, CSO, Sands, Springboard, Health Foundation, VmIA Academic Centre for Women’s Health University of Bristol
Myths Academic Centre for Women’s Health University of Bristol
Myths • Training is not needed • Training cannot be evaluated • Simulation is “toys for boys” • Hi-fi is hi-tech • Obstetricians should train separately from anaesthetists and midwives • Working in teams is easy Academic Centre for Women’s Health University of Bristol
Evidence Academic Centre for Women’s Health University of Bristol
Academic Centre for Women’s Health University of Bristol
Academic Centre for Women’s Health University of Bristol
Academic Centre for Women’s Health University of Bristol
Academic Centre for Women’s Health University of Bristol
Academic Centre for Women’s Health University of Bristol
Effective Training Academic Centre for Women’s Health University of Bristol
Effective Training • Practical – simulation • Multi-Professional • Teamwork & Communication training • Local training • Local incentives Academic Centre for Women’s Health University of Bristol
Maternity Services in England Academic Centre for Women’s Health University of Bristol
Claims - Value 3,332,916 3,500,000 CNST, by Value, 1995-2008, NHSLA 3,000,000 2,500,000 Value (£000) 2,000,000 1,500,000 1,283,208 966,006 1,000,000 450,111 500,000 137,610 100,897 77,546 75,938 23,074 14,257 9,891 9,578 7,352 0 Obstetrics & Gynaecology Surgery Accident & Emergency Medicine Psychiatry/Psychol/Mental Health Anaesthesia Radiology Pathology Paramedical Support Services Ambulance Public Health Nursing Primary Care (GP) Specialty Academic Centre for Women’s Health University of Bristol
Multi-professional Teams Academic Centre for Women’s Health University of Bristol
Simulation Academic Centre for Women’s Health University of Bristol
Simulation Academic Centre for Women’s Health University of Bristol
The SaFE Study 24 teams 140 staff Hospital SimCentre Clinical Clinical The SaFE Study Hospital SimCentre Clinical+T eamwork Clinical+T eamwork S imulation a nd F ire drill E valuation Academic Centre for Women’s Health University of Bristol
Individual Skills: Shoulder Dystocia Academic Centre for Women’s Health University of Bristol
High-Tech Simulation: Force Monitoring Academic Centre for Women’s Health University of Bristol
Hi-fidelity Academic Centre for Women’s Health University of Bristol
Training is needed • 43% could not deliver shoulder dystocia • Large forces 66%>100 N, 28%>150 N, 11% applied more than 200 N • Poor teamwork • Poor communication with patient actor Crofts Obstet Gynecol 2007 Crofts AJOG 2008 Siassakos Resus 2011 Siassakos Simul Healthc 201 1 Academic Centre for Women’s Health University of Bristol
Training is useful Improved Clinical Task Performance: essential drugs, life support Improved Individual KSA Retention of knowledge up to 12 months Crofts, Obstet Gynecol 2008 Ellis, Obstet Gynecol 2008 Crofts, BJOG 2008 Crofts, Qual Saf Healthc 2008 Crofts, Obstet Gynecol 2007 Crofts, BJOG 2007 Academic Centre for Women’s Health University of Bristol
Individuals Vs Teams Those training for SD with the high-tech mannequin: • significantly less likely to call for paediatric support (OR=0.30, CI=0.14 – 0.67, p=0.003) • fewer actions that require team effort: McRoberts, suprapubic pressure (OR=0.16, CI=0.02 – 1.40, p=0.099) Academic Centre for Women’s Health University of Bristol
NICE Guideline Academic Centre for Women’s Health University of Bristol
Guidance to Practice Academic Centre for Women’s Health University of Bristol
Coalface: NICE Sticker Reassuring Non-reassuring Abnormal Baseline rate 110 – 160 100 – 109 <100 Comments:- (bpm) 161 - 180 >180 Variability 5 bpm or more <5 for 40 mins or < 5 for 90 mins or Comments:- CTG on (bpm) more but <90 min more for 60 mins so far Accelerations Present None Comments:- Decelerations None Early Atypical variable Comments:- Variable Late Unprovoked Single prolonged Single prolonged decelerations deceleration up to 3 deceleration > 3 mins mins Opinion Normal CTG Suspicious CTG Pathological CTG (All four features (One non-reassuring (two or more non-reassuring or one or more abnormal features) reassuring) feature) Dilatation Not assessed Comments:- Not contracting Contractions ….:10 Action Urgent transfer to tertiary unit and review by senior obstetrician Date ……………………… Time………………… Signature………………………………………………. Status…………………………. Academic Centre for Women’s Health University of Bristol
Teamwork to embed implementation Academic Centre for Women’s Health University of Bristol
Effective Team Training Academic Centre for Women’s Health University of Bristol
Train to improve safety P<0.05 P<0.001 Draycott, BJOG 2006 & Obstet Gynecol 2009 Siassakos, BJOG 2009 Academic Centre for Women’s Health University of Bristol
Perinatal Outcomes Neonatal outcomes pre and post implementation of change Training programme 100 Rate per 10,000 liveborn babies 90 80 Goal: 70 at least 25% reduction 60 50 Sample: 40 19,460 babies 30 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 Year Five minute Apgar less than 7 HIE (All) HIE (Moderate/Severe) 5 ’ Apgar p=0.00042 HIE p=0.0176 ( χ 2 for trend) Academic Centre for Women’s Health University of Bristol
Keep improving Diagnosis-Delivery Interval (DDI) in cases of cord prolapse pre- and post- implementing change 33 Our median DDI at T SMH (minutes) r 30 a i 27 n Median DDI Target i 24 n (minutes) DDI (minutes) g 21 18 P r 15 o g 12 r a 9 m m 6 e Pre-Training Post-Training 3 0 1993 1996 1999 2002 2005 Academic Centre for Women’s Health University of Bristol
Teamwork Culture (Sexton et al) North SouthWest USA UK UK USA USA NZ Bristol England Maternity ORs ICUs ICUs ORs ICUs Mean Maternity untis (SD) Units Teamwork 76.1 72.5 68.25 74.3 71.7 65.7 71.7 67.9 climate (12.5) Safety 74.0 69.3 N/A 67.7 69.6 68.8 69.6 63.8 climate (13.4) Job 71.9 65.5 N/A 60.7 70.1 68.6 54.7 71.7 satisfaction (16.1) Stress 65.0 70.8 N/A 64.2 54.7 67.2 57.5 53.7 recognition (17.6) Perceptions 47.0 47.5 N/A 44.6 47.6 54.1 70.1 59.9 of mgt (16.8) Working 62.6 59.9 N/A 59.6 57.5 58.3 47.6 45.3 conditions (14.6) Academic Centre for Women’s Health University of Bristol
Local Incentives Obstetric 10 Damages/million LA/1000 9 8 7 6 5 4 3 2 1 0 95/96 96/97 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 Academic Centre for Women’s Health University of Bristol
Long term effect of training 0.4 0.35 BPI at 12 months per SD (per 1000 births) 0.3 0.25 0.2 0.15 0.1 0.05 0 Pre 4 years post 10 years post Academic Centre for Women’s Health University of Bristol
24 teams 140 staff The SaFE Study Hospital SimCentre S imulation a nd F ire drill Clinical Clinical E valuation Hospital SimCentre Clinical+T eamwork Clinical+T eamwork Academic Centre for Women’s Health University of Bristol
Hypothesis • Some teams are more effective than others (even before training) • The variation may be explained by certain individual / team characteristics • Discovering these characteristics could help inform better team training Academic Centre for Women’s Health University of Bristol
Correlations • No correlation between team performance (time to give essential drug) and individual KSA • Significant positive correlation between team performance & teamwork (Weller) scores skills (tau b =0.54, p<0.001) behaviours (tau b =0.41, p=0.001), overall teamwork (tau b =0.51, p<0.001) Siassakos, BJOG 2010 & Resuscitation 2011 Academic Centre for Women’s Health University of Bristol
Analysis Academic Centre for Women’s Health University of Bristol
Academic Centre for Women’s Health University of Bristol
Academic Centre for Women’s Health University of Bristol
Safer Teams St State th the emergency early rly Hand over r in in a str tructured way (SBAR) All llocate tasks with ith clo lose sed-lo loops (directed-acknowledged-executed-confirmed) Communic icate sit situatio ion & goals ls of management with ith parents Siassakos, BJOG 2011; Simul Healthc 2011; QHR 2012; ACTA 2013 Academic Centre for Women’s Health University of Bristol
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