The authors showcase a program obstetric hospitalists created for internal use, and then expanded to providers in the prehospital environment.
Introduction
There are 1,200 annual transports for women in the peripartum period provided by emergency medical services (EMS) in Middle Tennessee.1 While this number comprises only 0.5% of all transports, these transports can include labor, complications of labor such as shoulder dystocia, breech presentation or precipitous delivery. Other potential encounters can include life-threatening diagnoses such as acute severe hypertension/pre-eclampsia, eclampsia or maternal hemorrhage. The California Maternal Quality Care Collaborative has identified maternal hypertension and hemorrhage as the two most preventable causes of maternal morbidity and mortality.2 Possessing the knowledge to identify and to initiate management of these emergencies in the EMS setting is invaluable. Biannual National Registry Recertification of EMS personnel requires 30 minutes of obstetric emergency training each year.3
Obstetric simulation training was implemented in 2010 at Ascension Saint Thomas Hospital Midtown and providers are required to complete the simulation biannually. This training satisfies requirements for obstetric certification as outlined and facilitated by the Ascension Saint Thomas Office of Continuing Medical Education.4 As emergent obstetrical scenarios do not occur on a daily basis, simulation is a viable option for practicing real-life scenarios and maintaining skills. It seeks not only to provide more education in emergency scenarios but also to foster communication among team members. Some of the founding faculty who designed and initiated the program have continued in the role of instructor to this day. Exposure to Ascension outreach programs connected the simulation faculty with regional EMS agencies and led to education and training suited for the audience and skills of emergency providers. These training sessions have been held at fire departments, EMS conferences and emergency departments. A survey follows each instruction and training session, and feedback reveals that this format is a helpful and effective way to instill these important management algorithms.
Related
- How to Assess & Treat Common Pregnancy Complications
- A Guide to Integrating Simulation into EMS Education
- Standardization of EMS Simulation Activities Improves the Learning Experience
Although OB/GYN hospitalists serve as inpatient specialists primarily on labor and delivery, this role enables them to do outreach beyond the walls of the hospital to first responders. This OB emergency training and involvement in the community is not currently a requirement by the Joint Commission to offer such services. However, it is required that these services are offered in the emergency department. The Joint Commission states that a requirement is to conduct drills at least annually of all those providers potentially involved in a hemorrhage situation and to perform a debrief after so as to have continued quality improvement when these situations arise.5 These same criteria apply to severe hypertension and pre-eclampsia.6 These quality improvement measures are guidelines for emergency departments and labor and delivery alike; however, they are not part of the EMS system. This simulation program as described above fills that void and helps to fortify those providers in the prehospital setting who can certainly make a difference in patient outcomes. In addition, the coordination and facilitation by the Office of Continuing Medical Education supports the Accreditation Council for Continuing Medical Education criteria which promotes collaboration with community organizations to address population health priorities.
To enhance this part of the curriculum, the group of physicians who are part of Ascension Saint Thomas Obstetric Hospitalist Program have created a training program that involves not only lectures but also hands-on simulation for several obstetrical scenarios further described in the next section.
Materials and Methods
Physicians in the OB/GYN hospitalist group at Ascension Saint Thomas Hospital Midtown created an education and simulation program for common and rare obstetrical events. This program includes CME-accredited instruction on the uncomplicated vaginal delivery, management of labor complications (umbilical cord prolapse, shoulder dystocia, breech presentation), obstetric hemorrhage, pregnancy associated hypertension, eclampsia and maternal code. This consists of an hour-long PowerPoint presentation with a question and answer session and a subsequent hour-long hands-on simulation session with both low-fidelity and high-fidelity models led by a hospitalist instructor. The low-fidelity model of the life-size maternal pelvis and neonatal manikin is used to practice vaginal deliveries (Limbs and Things – Birthing Simulator – PROMPT Flex – Standard). During the simulation, learners have hands-on practice delivering a baby with standard maneuvers for a spontaneous vaginal delivery as well as a few maneuvers for reducing shoulder dystocia. The maneuvers taught are McRoberts position with suprapubic pressure, rotational maneuvers, and the Gaskin all-fours position. These options are in alignment with the skill level and physical exam components learned by these providers. Learners work in pairs during deliveries to practice calm and direct communication. This setup is in correlation to working in pairs as they do in their careers.
The high-fidelity model simulates maternal severe hypertension, eclampsia, cardiac arrest, and hemorrhage (Gaumard – NOELLE S574-100 – Maternal and Neonatal Birthing Simulator). This model has programmable maternal vital signs and fetal heart rate monitoring as well as can simulate maternal seizure activity and vaginal bleeding. The learners respond to scripted scenarios of acute severe hypertension and eclampsia where they practice skills on individual and team-based levels. The involved interprofessional team members assess the patient and can then call for administration of magnesium sulfate and appropriate anti-hypertensives that they have available in their ambulances. For hemorrhage, interventions such as fundal massage, placental delivery and oxytocin administration are reviewed. Each has different assigned roles such as an EMT, nurse, charge nurse, physician and family member. The learners have open dialog with the instructor as well to answer any additional questions and details not provided by the scenario template. After completion of the simulations, there is an electronic survey that is accessed with a QR code or website. The survey polls the effectiveness of the current session as well as additional OB experiences the provider has had. There are also questions as to what knowledge or knowledge gaps the learner had prior to the training and then what improvements can be made in the future.
Results
Since 2019, these trainings have occurred in various counties in middle Tennessee including Lincoln, Davidson, Marshall, Williamson, Maury, Rutherford, Bedford and Hickman. The annual attendance at these events has notably increased from 43 to 147 in the past three years. Most of the training occurs at EMS in-service events or multidisciplinary education events at fire departments or conference centers. At each of the events, the same subjects are covered and a survey is distributed at the end of the session. This survey has evolved over the past three years from a paper evaluation to an electronic Google Form that can be accessed easily through a QR code or a hyperlink (Fig. 1). In 2019 and 2020, the survey contained general questions about the quality of the training and the speakers. In 2021, the survey was updated to include more specific obstetric questions polling trainees’ prior educational experiences as well as what clinical experiences with deliveries, seizures, hemorrhage, and hypertension they have encountered in the field (Fig. 2).
Figure 1. 2019-2020 OB Simulation Evaluation.
Of the 147 attendees from 2021, there were 59 survey responses (40%). Eighty-two percent of learners (48/59) had never attended an OB education training although 39% have delivered a baby in a prehospital setting (23/59). Thirty-four percent have encountered hypertension or seizure related to pregnancy (20/59). Thirteen-and-a-half percent indicated increased knowledge and comfort with recognizing and treating severe acute hypertension (8/59). Ten percent mentioned feeling more comfortable managing a shoulder dystocia (6/59). Eighty-three percent of respondents who commented about shoulder dystocia management were paramedics (5/6). Seventeen percent stated that they felt more prepared to handle obstetric emergencies and maternal code (10/59). Twenty percent mentioned the importance of treating severe hypertension with antihypertensives such as hydralazine and labetalol as well as using magnesium sulfate for seizure prophylaxis (12/59). One attendee stated that he administered a magnesium sulfate bolus and labetalol for a patient with acute severe hypertension postpartum, and she was able to arrive at the hospital safely for further treatment. However, respondents also shared that some of these life-saving medications are not readily available on ambulances.
Discussion
Simulation is an artificial representation of real events, and training goals are achieved through simulation of deliveries and experiential learning for continuous practice and improvement of skills.7 The benefits of simulation are that it is low risk, provides for isolation and repetition of certain tasks or skills, feels realistic, and relies heavily on active participation of learners. High-and low-fidelity simulations help to address these common root causes of medical errors: communication breakdowns, human failure and organizational transfer of knowledge. The Joint Commission stresses that breakdown in communication and teamwork is the root cause of most patient harm.8
Many learners commented on the effectiveness of the hands-on simulations and felt more comfortable performing vaginal deliveries and actively managing acute severe hypertension and eclampsia. In conversation with the almost 40% of learners who had previously been involved in a vaginal delivery, most babies had already delivered upon arrival or did so spontaneously without complication. These outcomes are what the majority will experience but many expressed less anxiety about handling these deliveries or their complications should they face them in the future. Emergencies often cause anxiety and stress that can affect communication and lead to mistakes.
The two-hour training session quadruples the amount of required time that is necessary for recertification and comprises a small part of what they manage, but most learners were enthusiastic that these simulations should be presented annually. This sentiment aligns with a recent survey released by the National Association of Emergency Medical Technicians (NAEMT) and American College of Obstetricians and Gynecologists (ACOG) on Maternal Health Awareness Day 2022. This survey stated that from 1,700 EMS providers polled, more than 75% want additional training with patients and problems in the peripartum period.9 Additionally, the majority of providers were from rural communities with at least a 10-30 minute and up to two hours transport time.10 Part of ACOG’s Commitment to Action on eliminating preventable maternal mortality is to “enhance understanding among nonobstetric health care professionals . . . [and] to stabilize or treat patients who present outside the obstetric setting.11 This goal is already being accomplished with these EMS trainings on obstetric emergencies, and the hope is to continue expanding to surrounding areas.
Some of the barriers encountered to implementing the training are availability of medications in the EMS ambulances. Many providers shared that they do not have Pitocin and Cytotec to be used during a delivery or as management for an obstetric hemorrhage. The medications included on the ambulances are dependent on the medical director for each county so are not universal. There have been meetings with the Tennessee Medical Director of EMS Services to update policies for management of peripartum problems and have the power to influence what is included in each county’s fleet of ambulances. A metric not collected in this study was the monetary impact these trainings have on the healthcare system. However, even without quantitative data, improvements and shorter time to appropriate management in these scenarios is likely. Simulation has been shown to be effective in significantly reducing malpractice claims due to increased patient safety through strengthening systems, timely care, and team communication.12 Simulation will continue to be an integral part of the OB/GYN hospitalist program to share these needed skills with first responders and non-obstetric communities.
References
1. Tennessee Department of Health, 2021.
2. Leonard SA, Kennedy CJ, Carmichael SL, Lyell DJ, Main EK. An Expanded Obstetric Comorbidity Scoring System for Predicting Severe Maternal Morbidity. Obstet Gynecol. 2020 Sep;136(3):440-449. doi: 10.1097/AOG.0000000000004022. PMID: 32769656; PMCID: PMC7523732.
3. NHTSA. National Emergency Medical Services Education Standards. 2009.
4. Graves CR, Smallwood GH, Bressman PL, Brown DH, et al. The Initiation of Simulation Training at a Large Community Hospital. Proceedings in Obstetrics and Gynecology. 2012 May; 2(3):9.
5. R3 Report. The Joint Commission. Issue 24, Aug 21 2019. PC.06.01.01.
6. R3 Report. The Joint Commission. Issue 24, Aug 21 2019. PC.06.01.03.
7. How Simulation Can Reduce Patient Risk. An Introduction for Risk Managers and Quality Improvement Specialists. Laerdal. 2016.
8. Ibid.
9. NAEMT, ACOG Survey Finds Need for More Education, Training on EMS Response to Obstetric Emergencies. ACOG. Jan. 21, 2022.
10. Ibid.
11. Ibid.
12. Laerdal.
