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Service Delivery Innovation Profile

Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes


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Snapshot

Summary

Multidisciplinary teams at the University of Kansas Hospital seek to improve the handling of obstetric emergencies by rehearsing team responses to emergency situations that can occur during a delivery. Using the PRactical Obstetric MultiProfessional Training (or PROMPT) model,1 the teams rehearse emergency care in various scenarios to achieve an optimal response, and then use this experience to improve their response to a real emergency. The program has reduced rates of cesarean delivery, brachial plexus injury (at least transient), and incidence of hypoxic ischemic encephalopathy, as well as decision-to-delivery times, the need for blood transfusions, and the incidence of acidemic newborns and shoulder dystocia injuries. In addition, anecdotal reports suggest that the program has improved management of emergency situations. Studies from the United Kingdom found that the program improved outcomes, task completion, medication administration, caregiver response times, and caregiver knowledge.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre-post implementation comparisons of rates of cesarean delivery, brachial plexus injury (at least transient), and incidence of hypoxic ischemic encephalopathy, as well as anecdotal reports on management of emergency situations, general trends in obstetric-related outcomes and malpractice premiums (with no hard data being available to document these trends). Data are also presented from two retrospective observational studies and two RCTs from settings in the United Kingdom.
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Developing Organizations

U.K. National Health Service; University of Kansas School of Medicine
Kansas City, KSend do

Date First Implemented

2007

Problem Addressed

Although relatively uncommon, obstetric emergencies still affect thousands of individuals and can have devastating consequences for the baby, family, and providers, and cost millions of dollars in malpractice insurance claims each year.1 Effective communication and teamwork can improve outcomes during obstetric emergencies, but clinical teams often are not prepared to react quickly and appropriately during these unpredictable events.
  • Relatively rare, but still affecting thousands: Birth trauma occurs in approximately 7.4 out of every 1,000 live births in the United States.2 For example, shoulder dystocia (when the baby's shoulders cannot move past the mother's pelvis during delivery), which occurs in approximately 5 percent of births,3 can lead to birth trauma if not handled properly. Serious forms of maternal morbidity are reported in an average of less than 1 percent of births; for example, maternal cerebrovascular accident occurs in less than 0.1 percent of births, while eclampsia and postnatal hemorrhage occur in approximately 0.1 percent and 2 percent of deliveries, respectively. However, with roughly 4 million deliveries annually, thousands of women and their babies still end up being affected by these events.4
  • Devastating consequences: Obstetric emergencies—particularly those resulting in birth trauma—are emotionally devastating to families and result in long-term costs to providers and society, including rapidly rising litigation expenses (leading some physicians to stop delivering babies altogether) and an escalation in use of costly cesarean sections and operative vaginal deliveries to minimize the potential for birth trauma in high-risk situations.5
  • Largely unrealized benefits of practicing team responses: The most common adverse events that occur during birth are largely preventable.1 For example, proper maneuvering can prevent injury in shoulder dystocia cases. Yet, up to 25 percent of deliveries in these cases result in an injury to the nerves that control movement and sensation in the arm, with permanent damage occurring in up to 10 percent of babies.3 Although simulation training can provide opportunities to hone the team's response during actual emergencies and prevent adverse events,6 very few hospitals have such programs in the United States.

What They Did

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Description of the Innovative Activity

Multidisciplinary teams simulate the most common obstetrical emergency situations and practice an optimal response. Clinicians then use what they learn during real emergency situations. The program includes didactic sessions on these common situations, the teaching and practicing of structured communication techniques to facilitate information sharing during actual emergencies, and simulations in which clinicians perform requisite skills and receive real-time feedback on their performance. Key elements of the program include the following:
  • Program logistics: All personnel working in the labor and delivery suite, including obstetrician/gynecologists, pediatricians, anesthesiologists, nurses, clerical staff, and others, attend a mandatory annual 2-day training through the PRactical Obstetric MultiProfessional Training (PROMPT) system. The University of Kansas Hospital offers the course quarterly, with roughly 50 individuals attending each session. Sessions are led by masters-level nurses and senior labor suite nursing staff who have completed PROMPT training previously.
  • Preparation for rehearsal: The sessions emphasize two key areas where care processes need to be improved—responses to common emergency scenarios and structured communication to facilitate information sharing during an actual emergency.
    • Optimal response to emergency scenarios: Didactic sessions outline the care steps clinicians should take to optimize outcomes when faced with an obstetric emergency. Sessions focus on the appropriate response to a variety of potential emergency situations that may occur, including maternal hemorrhaging, maternal arrest, eclampsia (convulsions), hypertensive crisis (a severe increase in the mother’s blood pressure that can lead to a stroke), umbilical cord prolapse (in which the cord passes through the cervix ahead of the baby), shoulder dystocia, breach delivery, forceps delivery, multiple gestation, and interpretation of fetal heart rate tracings. Sessions include didactic modules held during the morning, structured as a series of short (15-minute) lectures, followed by 15 minutes of audience participation allowing for questions, discussion of current practices, and suggestions for process change.
    • Structured communication techniques: Participants learn structured communication techniques as part of a didactic module and then watch a videotape of two different situations that illustrate poor and optimal communication. The session teaches an organized method for communicating vital information about the patient’s condition and instructions regarding equipment, testing, and staff. This initial communication is followed by the participant's repeating of the information to confirm receipt and understanding. Participants use these communication techniques in the simulations (see below), and are encouraged to use them in daily care situations. Participants also receive and learn to use forms to document communication.
  • Simulated rehearsals with real-time performance feedback: After the morning modules, participants take part in a half day of simulations that allow them to practice the care steps discussed earlier in the day. Five teams with 10 participants each rotate through five stations, each representing a different emergency scenario. In most cases, midwives, nurses, and medical students act as “patients,” sometimes, participants use a plastic pelvis and a baby doll for general teaching/demonstration purposes. (Occasionally, teams use high-fidelity simulation mannequins, but these are not necessary for the program.) During the simulation, the trainer reviews the team’s performance and offers real-time feedback regarding clinical and communication processes. For example, the trainer may stop the team to remind them of an omitted step or may change the simulation to reflect the negative consequence of forgetting that step.

Context of the Innovation

The University of Kansas Hospital, an academic institution with approximately 606 beds and 13 labor rooms, handles approximately 1,900 deliveries each year. Dr. Carl Weiner, Professor and Chair of the Department of Obstetrics and Gynecology, learned about PROMPT while attending a conference in New Zealand. Impressed by the randomized trial data supporting the link between the training and better birth outcomes, Dr. Weiner sought and received approval in 2006 for the University of Kansas Hospital to serve as the PROMPT representative in North America. PROMPT, developed in the United Kingdom’s National Health Service by a team led by Dr. Tim Dracott, is the only simulation model in obstetrics that has been shown via prospective clinical trials to improve patient outcomes.

Did It Work?

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Results

At the University of Kansas, the program has reduced rates of cesarean delivery, brachial plexus injury (at least transient), and incidence of hypoxic ischemic encephalopathy, as well as decision-to-delivery times, the need for blood transfusions, and the incidence of acidemic newborns and shoulder dystocia injuries. Anecdotal reports suggest that the program has improved management of emergency situations, and malpractice premiums have fallen since program implementation. Studies from the United Kingdom found that the program improved outcomes, task completion, medication administration, caregiver response times, and caregiver knowledge.

Results From University of Kansas Hospital
  • Improvement in outcomes: During the program's first three years, results included shorter decision-to-delivery times and to fewer blood transfusions, acidemic newborns, and shoulder dystocia injuries (specific data not available). Information provided in August 2012 indicates that, after 5 years of required annual training of all personnel who work on the labor and delivery unit of the University of Kansas Hospital, the rate of cesarean delivery has declined by 25 percent to 23.8 percent, brachial plexus injury (at least transient) has declined by approximately 50 percent, and the incidence of hypoxic ischemic encephalopathy has declined by over 40 percent. A detailed publication of the experience is being prepared.
  • Anecdotal reports of better management of emergency situations: Coincidentally, the hospital's labor and delivery unit faced three emergencies during the first week after the initial training: a postpartum hemorrhage, a baby with shoulder dystocia, and a breech delivery. Staff resolved all three emergencies successfully by using techniques practiced during simulations, achieving positive outcomes. All involved staff commented on how well prepared they felt to handle these cases as a result of the simulations. Anecdotal reports over the past 3 years suggest that clinician performance during emergency situations has improved since implementation of PROMPT.
  • Savings on annual liability premiums: Since adopting PROMPT, the hospital’s annual malpractice insurance premium has fallen significantly (actual cost savings not available).
Results From the United Kingdom
  • Better outcomes: A retrospective cohort observational study found that, after the introduction of PROMPT, the number of infants with Apgar scores less than or equal to 6 decreased from 86.6 to 44.6 per 10,000 births, and the number of infants with hypoxic-ischemic encephalopathy (central nervous system damage resulting from inadequate oxygen) decreased from 27.3 to 13.6 per 10,000 births.6 Another retrospective observational study found that the program led to a 70 percent reduction in brachial plexus injuries following shoulder dystocia.7
  • Improved task completion, medication administration, and response times for eclampsia patients: A randomized controlled trial (RCT) focused on the care of patients with eclampsia found that PROMPT training increased the completion rates for basic tasks (100 percent completion rates in the training group, compared with 87 percent in the control group); led to quicker completion of these tasks (27 vs. 55 seconds); increased administration of appropriate medications (92 vs. 61 percent); and reduced median administration time for these medications (by 116 seconds).8
  • Enhanced knowledge: A prospective RCT found that obstetrician and midwife knowledge about emergency management significantly increased after training, with scores on a 185-question multiple choice questionnaire increasing by an average of 20.6 points.9

Evidence Rating (What is this?)

Moderate: The evidence consists of pre-post implementation comparisons of rates of cesarean delivery, brachial plexus injury (at least transient), and incidence of hypoxic ischemic encephalopathy, as well as anecdotal reports on management of emergency situations, general trends in obstetric-related outcomes and malpractice premiums (with no hard data being available to document these trends). Data are also presented from two retrospective observational studies and two RCTs from settings in the United Kingdom.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Obtaining approval from senior leadership: Dr. Weiner proposed the adoption of the evidence-based program,6-9 PROMPT to senior hospital administrators, who reacted enthusiastically to the idea.
  • Obtaining and “Americanizing” PROMPT materials: Since PROMPT had been developed and tested in the United Kingdom, Dr. Weiner needed to secure approval to license and distribute program materials in the United States. After doing so, he amended the materials for American audiences by adjusting language and ensuring that the clinician relationships and organizational processes described reflected the U.S. health care system.
  • Selecting and training the trainers: Dr. Weiner identified staff to serve as trainers, selecting obvious choices for the role, including, for example, the director of nursing education and a perinatologist. He then administered the course to these individuals and held several rehearsals.
  • Piloting and rolling out program: Dr. Weiner held a “trial run” of the program during an abbreviated, half-day session that included obstetricians, faculty, and nurses. After this trial, the labor and delivery department scheduled all involved individuals (approximately 200 people) for one of two 2-day courses, conducted several days apart.
  • Adjusting schedule: Because training all individuals during the same week proved logistically difficult, the hospital now schedules sessions on a quarterly basis, with approximately 50 people attending each session.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
  • Costs: The primary costs relate to the labor expenses needed to provide patient coverage while staff members attend the program. Mannequin simulators for shoulder dystocia can also be purchased from manufacturers, but the course can be run without these mannequins or any other specialized simulation equipment. In addition, because the University of Kansas Hospital must pay PROMPT a royalty fee each time a U.S. hospital adopts the program, the hospital requires these adopters to pay a one-time fee equal to $1 per annual delivery to cover this expense.
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Funding Sources

University of Kansas Hospital
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Tools and Other Resources

Hospitals can purchase PROMPT materials from the University of Kansas. More information is available at the PROMPT Web site: http://www.promptmaternity.org/.

Adoption Considerations

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Getting Started with This Innovation

  • Obtain commitment from all parties: Senior management, clinicians, and frontline staff must all believe in the value of process improvement. Although academic medical centers can require faculty to participate, community hospitals may find it more difficult to mandate that physicians do so.
  • Customize to site-specific characteristics: Adopters should customize the program to reflect the care and operational processes within their own institutions.

Sustaining This Innovation

  • Repeat annually: Sessions should be repeated annually to refresh clinician skills in handing these relatively rare events. PROMPT studies have shown that the skills and learning persist for approximately 1 year, but then begin to wane if not refreshed.
  • Seek insurer support: Share data with insurers on program outcomes and request that they lower malpractice premiums for hospitals and providers that participate in the program. These premium reductions can serve as a strong incentive to participate.

Spreading This Innovation

The National Health Service requires use of PROMPT or a similar program annually by every hospital offering maternity services in the United Kingdom. In the United States, one hospital is in the process of contracting with the University of Kansas Hospital to provide PROMPT; several others have also expressed interest. In 2014, a nationwide campaign to train hospitals in these methods will begin.

Additional Considerations

The PROMPT program has won numerous awards in the United Kingdom, including (but not limited to):

  • Obstetrics & Gynaecology Team of Year 2007 (Royal College of Obstetricians and Gynaecologists, United Kingdom)
  • Hospital Doctor of the Year 2007 (Royal College of Obstetricians and Gynaecologists, United Kingdom)
  • Clinical Category Winner and Overall Winner, December 2008 (National Institute for Clinical Excellence Shared Learning Awards)

More Information

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Contact the Innovator

Carl Weiner, MD
The K.E. Krantz Professor and Chair
Department of Obstetrics and Gynecology
University of Kansas School of Medicine
3901 Rainbow Boulevard, MS 2028
Kansas City, KS 66160-7316
Phone: (913) 588-6250
Fax: (913) 588-3298/6271
E-mail: cweiner@kumc.edu

Innovator Disclosures

Dr. Weiner has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Crofts JF, Ellis D, Draycott TJ, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation centre, and teamwork training. BJOG 2007;114(12):1534-41. [PubMed]

Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006;113(2):177-82. [PubMed]

Vierthaler M. Training Program Reborn at KU. August 13. 2008. Lawrence Journal World & News. Available at: http://www2.ljworld.com/news/2008/aug/13/training_program_reborn_ku.

The University of Kansas Hospital. The University of Kansas Hospital Offers Unique Training In Delivering Babies. August 5, 2008. Available at: http://www.kumed.com/newsroom/news/unique-training-in-delivering-babies

Footnotes

1 Vierthaler M. Training Program Reborn at KU. August 13. 2008. Lawrence Journal World & News. Available at: http://www2.ljworld.com/news/2008/aug/13/training_program_reborn_ku/.
2 Institute for Healthcare Improvement. Seton Family of Hospitals: Where the Birth Trauma Rate is Essentially Zero. IHI Annual Progress Report, 2008. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories/SetonBirthTraumaRateIsEssentiallyZero.aspx.
3 The University of Kansas Hospital. The University of Kansas Hospital Offers Unique Training In Delivering Babies. August 5, 2008. Available at: http://www.kumed.com/newsroom/news/unique-training-in-delivering-babies
4 Danel I, Berg C, Johnson CH. Magnitude of maternal morbidity during labor and delivery: United States, 1993-1997. Am J Public Health 2003;93(4):631-4. [PubMed]
5 MacLennon A, Nelson KB, Hankins G, et al. Who will deliver our grandchildren: implications of cerebral palsy litigation. JAMA 2005;294(13):1688-90. [PubMed]
6 Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006;113:177-82. [PubMed]
7 Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008 Jul;112(1):14-20. [PubMed]
8 Ellis D, Crofts JF, Hunt LP, et al. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol. 2008;111(3):723-31. [PubMed]
9 Crofts JF, Ellis D, Draycott TJ, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation centre, and teamwork training. BJOG 2007;114:1534-41. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 28, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 12, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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