Royal College of Surgeons and South West Professional Affair irs - - PowerPoint PPT Presentation

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Royal College of Surgeons and South West Professional Affair irs - - PowerPoint PPT Presentation

Nov 01, 2022 43 likes •576 views

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 Womens Health, Southmead Hospital Lead for

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Academic Centre for Women’s Health University of Bristol

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

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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

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Academic Centre for Women’s Health University of Bristol

Myths

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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
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Academic Centre for Women’s Health University of Bristol

Evidence

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

Effective Training

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Academic Centre for Women’s Health University of Bristol

Effective Training

  • Practical – simulation
  • Multi-Professional
  • Teamwork & Communication training
  • Local training
  • Local incentives
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Academic Centre for Women’s Health University of Bristol

Maternity Services in England

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Academic Centre for Women’s Health University of Bristol

Claims - Value

3,332,916 1,283,208 966,006 450,111 137,610 100,897 77,546 75,938 23,074 14,257 9,891 9,578 7,352 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 Obstetrics & Gynaecology Surgery Medicine Accident & Emergency Anaesthesia Psychiatry/Psychol/Mental Health Radiology Pathology Ambulance Paramedical Support Services Public Health Nursing Primary Care (GP) Specialty Value (£000)

CNST, by Value, 1995-2008, NHSLA

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Academic Centre for Women’s Health University of Bristol

Multi-professional Teams

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Academic Centre for Women’s Health University of Bristol

Simulation

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Academic Centre for Women’s Health University of Bristol

Simulation

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Academic Centre for Women’s Health University of Bristol

The SaFE Study Simulation and Fire drill Evaluation

The SaFE Study

24 teams 140 staff Hospital Clinical Hospital Clinical+T eamwork SimCentre Clinical SimCentre Clinical+T eamwork

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Academic Centre for Women’s Health University of Bristol

Individual Skills: Shoulder Dystocia

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Academic Centre for Women’s Health University of Bristol

High-Tech Simulation: Force Monitoring

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Academic Centre for Women’s Health University of Bristol

Hi-fidelity

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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 2011

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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

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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)

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Academic Centre for Women’s Health University of Bristol

NICE Guideline

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Academic Centre for Women’s Health University of Bristol

Guidance to Practice

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Academic Centre for Women’s Health University of Bristol

Coalface: NICE Sticker

Reassuring Non-reassuring Abnormal Baseline rate (bpm) 110 – 160 100 – 109 161 - 180 <100 >180 Comments:- Variability (bpm) 5 bpm or more <5 for 40 mins or more but <90 min < 5 for 90 mins or more Comments:- CTG on for 60 mins so far Accelerations Present None Comments:- Decelerations None Early Variable Single prolonged deceleration up to 3 mins Atypical variable Late Single prolonged deceleration > 3 mins Comments:- Unprovoked decelerations Opinion Normal CTG (All four features reassuring) Suspicious CTG (One non-reassuring feature) Pathological CTG (two or more non-reassuring or one or more abnormal features) Dilatation Not assessed Comments:- Not contracting Contractions ….:10 Action Urgent transfer to tertiary unit and review by senior obstetrician Date ……………………… Time………………… Signature………………………………………………. Status………………………….

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Academic Centre for Women’s Health University of Bristol

Teamwork to embed implementation

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Academic Centre for Women’s Health University of Bristol

Effective Team Training

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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

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Academic Centre for Women’s Health University of Bristol

Perinatal Outcomes

5’ Apgar p=0.00042 HIE p=0.0176 (χ2 for trend)

Neonatal outcomes pre and post implementation of change

10 20 30 40 50 60 70 80 90 100 1996 1997 1998 1999 2000 2001 2002 2003 Year Rate per 10,000 liveborn babies

Five minute Apgar less than 7 HIE (All) HIE (Moderate/Severe) Goal: at least 25% reduction Sample: 19,460 babies Training programme

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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

3 6 9 12 15 18 21 24 27 30 33

1993 1996 1999 2002 2005 DDI (minutes)

Our median DDI at SMH (minutes) Median DDI Target (minutes)

T r a i n i n g P r
  • g
r a m m e Pre-Training Post-Training
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Academic Centre for Women’s Health University of Bristol

Teamwork Culture (Sexton et al)

North Bristol Mean (SD) SouthWest England Maternity Units USA Maternity untis UK ORs UK ICUs USA ICUs USA ORs NZ ICUs Teamwork climate 76.1 (12.5) 72.5 68.25 74.3 71.7 65.7 71.7 67.9 Safety climate 74.0 (13.4) 69.3 N/A 67.7 69.6 68.8 69.6 63.8 Job satisfaction 71.9 (16.1) 65.5 N/A 60.7 70.1 68.6 54.7 71.7 Stress recognition 65.0 (17.6) 70.8 N/A 64.2 54.7 67.2 57.5 53.7 Perceptions

  • f mgt

47.0 (16.8) 47.5 N/A 44.6 47.6 54.1 70.1 59.9 Working conditions 62.6 (14.6) 59.9 N/A 59.6 57.5 58.3 47.6 45.3

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Academic Centre for Women’s Health University of Bristol

Local Incentives

1 2 3 4 5 6 7 8 9 10 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 Obstetric Damages/million LA/1000
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Academic Centre for Women’s Health University of Bristol

Long term effect of training

0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 Pre 4 years post 10 years post

BPI at 12 months per SD (per 1000 births)

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Academic Centre for Women’s Health University of Bristol

The SaFE Study Simulation and Fire drill Evaluation

24 teams 140 staff

Hospital Clinical Hospital Clinical+T eamwork SimCentre Clinical SimCentre Clinical+T eamwork

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Academic Centre for Women’s Health University of Bristol

Hypothesis

  • Some teams are more effective than
  • thers (even before training)
  • The variation may be explained by certain

individual / team characteristics

  • Discovering these characteristics could

help inform better team training

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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 (taub=0.54, p<0.001) behaviours (taub=0.41, p=0.001), overall teamwork (taub=0.51, p<0.001)

Siassakos, BJOG 2010 & Resuscitation 2011

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Academic Centre for Women’s Health University of Bristol

Analysis

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

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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

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Academic Centre for Women’s Health University of Bristol

Safe Leaders

Siassakos, ACTA 2013

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Academic Centre for Women’s Health University of Bristol

Teamwork

Integrated in drills

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Academic Centre for Women’s Health University of Bristol

SBAR

Domain Expected statement S Stated which emergency (situation) The woman is bleeding, and has lost more than 2 litres B Background history (key points) mentioned She is refusing blood products (Jehova’s witness) A Assessment of situation and severity Code Red Haemorrhage R Recommendation for initial action Check advance directive Call consultant obstetrician, anaesthetist, and haematologist

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Academic Centre for Women’s Health University of Bristol

THISTLE Stepped-wedge RCT

‘ e’ ’

Time% (months) Control period Intervention period inc. local training of trainees ** Follow-up Step% Step% 1 Step% 2 Step% 3 Step% 4 Step% 5 ! 6 6 12 18 24 30 Training of local trainers (T3) * Each row represents a group of 4 maternity units ** Steps 2 & 3 included in the process and economics
  • evaluation. Set-up to occur in parallel with THISTLE’s Step 1
(excluded)
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Academic Centre for Women’s Health University of Bristol

Unpacking the Box

‘ ’

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Academic Centre for Women’s Health University of Bristol

Surgery

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

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Academic Centre for Women’s Health University of Bristol

Myths, History, Safety

‘For they had learned that true safety was to be found in long previous training, and not in uttering eloquent exhortations’

Spartans, Battle of Mantineia, 418 BC

Thucidides

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Academic Centre for Women’s Health University of Bristol

Thank you

jsiasakos@me.com twitter.com/DSiassakos