Post on 21-Apr-2020
THE USE OF SIMULATION IN THE USE OF SIMULATION IN OBSTETRIC ANESTHESIAOBSTETRIC ANESTHESIA
Georges Georges SavoldelliSavoldelli , MD, , MD, MEdMEdService dService d ’’AnesthAnesth éésiologiesiologie
Hôpitaux Universitaires de GenHôpitaux Universitaires de Gen èèveve
Annual Meeting SGAR/SSARAnnual Meeting SGAR/SSARSatellite Meeting ASAO/SAOASatellite Meeting ASAO/SAOA
Fribourg, Oct 30Fribourg, Oct 30 thth 20082008
La La «« machinemachine »» de Madame du de Madame du CoudrayCoudrayXVIIIXVIIIthth Century; MusCentury; Mus éée Flaubert de Flaubert d ’’histoire de la mhistoire de la m éédecine, Rouendecine, Rouen
Plan
�� What is simulation ?What is simulation ?
�� Why should we use simulationWhy should we use simulation --based training ?based training ?
�� Challenges in obstetric anesthesiaChallenges in obstetric anesthesia
�� Simulation in obstetric anesthesiaSimulation in obstetric anesthesia
�� ConclusionsConclusions
Simulation is…
�� A situation or environment created to allow A situation or environment created to allow persons to experience a representation of real persons to experience a representation of real events for the purpose of: events for the purpose of:
–– LearningLearning–– PracticePractice–– Evaluation / TestingEvaluation / Testing–– Gaining understanding of systemsGaining understanding of systems–– Gaining understanding of human actionsGaining understanding of human actions
(Harward CMS Definition)
Simulation allows...
�� The creation of a safe environment in which to:The creation of a safe environment in which to:
–– Teach, learn and practice Teach, learn and practice �� Technical skillsTechnical skills�� Non technical skillsNon technical skills�� Responses to both common and rare emergenciesResponses to both common and rare emergencies
–– Elicit responses to clinical scenarios in order to identify areaElicit responses to clinical scenarios in order to identify area s s for improvement at the level offor improvement at the level of
�� Individuals, teams and systemsIndividuals, teams and systems
–– Promote reflection and provide corrective feedbackPromote reflection and provide corrective feedback–– Explore end results of errorsExplore end results of errors–– Trial run new procedures and/or processesTrial run new procedures and/or processes
The spectrum of medical simulators
Ziv A, Acad Med 2003
Computer driven, fullComputer driven, full --length length mannequins. Simulated anatomy mannequins. Simulated anatomy and physiology. Lifelike setting.and physiology. Lifelike setting.
Realistic patient simulatorsRealistic patient simulators
HiHi--fi visual, audio, touch cues. fi visual, audio, touch cues. Virtual reality devices.Virtual reality devices.
Complex task trainersComplex task trainers
Programs to teach and assess Programs to teach and assess clinical knowledge, PBL, clinical knowledge, PBL, decisiondecision --making, making, managementmanagement ……..
ScreenScreen --based computer based computer simulatorssimulators
Actors trained to roleActors trained to role --play play patientspatients
Simulated/standardized patientSimulated/standardized patient
Models or mannequinsModels or mannequinsLowLow --tech simulatorstech simulators
Description/examplesDescription/examplesTool or approachTool or approach
Full scale realistic patient simulators
Debriefing room
Control room
High fidelity mannequin + simulated environment
Plan
�� What is simulation ?What is simulation ?
�� Why should we use simulationWhy should we use simulation --based training ?based training ?
�� Challenges in obstetric anesthesiaChallenges in obstetric anesthesia
�� Simulation in obstetric anesthesiaSimulation in obstetric anesthesia
�� ConclusionsConclusions
Why should we use simulation-based training ?
Educational rationaleEducational rationale
�� Principles of Principles of ““ Adult learningAdult learning ””–– Contextual learningContextual learning–– Experiential learningExperiential learning–– Reflective practiceReflective practice
�� Other reasons:Other reasons:–– Specific competencesSpecific competences–– Possibility to repeat the exercises (drills) Possibility to repeat the exercises (drills) –– Rare eventsRare events
The experiential cycle in simulation
Simulation experience
Reflection andinterpretation
Compare to existing
knowledge
Formation ofnew construct
1010--2020’’
DDéébriefingbriefing4545’’--6060’’
Why should we use simulation-based training ?
�� PsychoPsycho --cognitive argumentscognitive arguments–– Memory and emotionsMemory and emotions
�� Safety and risk managementSafety and risk management–– No risk for the patients No risk for the patients –– Desired outcomes = improved safety and patient careDesired outcomes = improved safety and patient care
““ To err is humanTo err is human ”” Institute of Medicine, 1999Institute of Medicine, 1999
�� Ethical imperativeEthical imperative
Plan
�� What is simulation ?What is simulation ?
�� Why should we use simulation training ?Why should we use simulation training ?
�� Challenges in obstetric anesthesiaChallenges in obstetric anesthesia
�� Simulation in obstetric anesthesiaSimulation in obstetric anesthesia
�� ConclusionsConclusions
The labor and delivery suite:A challenging environment
Characterized by:Characterized by:�� Acute stressAcute stress�� Heavy workloadHeavy workload�� 2 (or more) patients2 (or more) patients�� High stakes for decisions High stakes for decisions
and actions errorsand actions errors
Requires intense:Requires intense:�� Planning and anticipationPlanning and anticipation�� Error free vigilanceError free vigilance�� Effective CommunicationEffective Communication�� Effective multidisciplinary Effective multidisciplinary
teamwork teamwork
Ex Utero Intrapartum TreatmentKern C et al, SMW 2007
Planning / preparationAnticipationCoordination
Joint Commission in the US
Communication and teamwork issues are the Communication and teamwork issues are the most common contributors to:most common contributors to:
�� Unexpected Unexpected perinatalperinatal deaths and injuriesdeaths and injuries
�� Unexpected maternal deaths and injuriesUnexpected maternal deaths and injuries
Risk reduction in obstetric practice requires training in :
� Obstetric and neonatal emergencies (“fire drills”)
� Multidisciplinary team working
� Human factors
How can we improve teamwork in obstetric ?
� Didactic sessions are effective to introduce teamwork concepts and influence safety attitudeEx: “The ENSEMBLE Project at the HUG”
Haller G et al, International Journal for Quality i n Health Care , 2008
� However: ““ Translation of teamwork concepts Translation of teamwork concepts into clinical behaviors into clinical behaviors ……requires a deeper level requires a deeper level of integration and hands on experience through of integration and hands on experience through clinical team simulations/drills combined with a clinical team simulations/drills combined with a structured curriculumstructured curriculum …”…”
Guise JM and Segel S, Best Pract & Res Clin Obstet Gyna ecol 2007
Plan
�� What is simulation ?What is simulation ?
�� Why should we use simulation training ?Why should we use simulation training ?
�� Challenges in obstetric anesthesiaChallenges in obstetric anesthesia
�� Simulation in obstetric anesthesiaSimulation in obstetric anesthesia
�� ConclusionsConclusions
� At HUG ≈ 1% of the CS are performed under GA !
� ≈ 10/4000 deliveries/year
� → Residents training may be insufficient and inadequate
� Simulation drills may complement clinical teaching
Scavone B et al, Anesthesiology 2006
Example of complex procedural skills:GA for emergency CS
Simulation and nonSimulation and non --technical skillstechnical skills
Anesthesia Residents (n=20)
Debriefing #1Session #1
Debriefing #3Session #31 month1 month
Debriefing #2Session #21 month1 month
Evaluation of technical by blind Evaluation of technical by blind raters using the ANTS scale systemraters using the ANTS scale system
Improvement in anesthesia trainees’non-technical skills
Improving multidisciplinary teamwork and communication at the HUG
�� Simulated scenarios to complement existing Simulated scenarios to complement existing didactic trainingdidactic training
�� Participants: Participants: –– ObstetriciansObstetricians–– MidwivesMidwives–– Anesthesiologists, Anesthesiologists, –– Nurse anesthetists, Nurse anesthetists, –– OR nursesOR nurses–– pediatricianspediatricians
Objectives of the session :
�� Highlight and discuss teamwork issues and Highlight and discuss teamwork issues and Crisis Resource Management principlesCrisis Resource Management principles during during critical obstetric emergenciescritical obstetric emergencies
�� Identify areas of improvementIdentify areas of improvement–– CommunicationCommunication–– CoordinationCoordination–– Cognitive biasCognitive bias–– New strategiesNew strategies
SBAR mnemonics
Effective SBAR communicationEffective SBAR communication
Scenario script:Scenario script:
33 year33 year --old G1 P0old G1 P0Refuses epidural analgesiaRefuses epidural analgesia
Umbilical cord Umbilical cord prolapseprolapseEmergency CS in the delivery roomEmergency CS in the delivery room
Effective SBAR communicationEffective SBAR communicationSituation: Situation: ““We have a cord We have a cord prolapseprolapse””Background: Background: ““ All OR are busyAll OR are busy ””Assessment: Assessment: ““ We have to do the CS hereWe have to do the CS here ””Recommendation: Recommendation: ““ Put her off to sleep ! Put her off to sleep ! ””
Effective SBAR communication
� Situation: “We have a cord prolapse”
� Background: “All OR are busy”
� Assessment: “We have to do the CS here”
� Recommendation: “Put her off to sleep ! ”
Communication and coordination
Lack of communicationLack of communication
↓↓
Leading to poor coordinationLeading to poor coordination
CRM and communicationCRM and communication
MeantMeant ……Is not saidIs not said
SaidSaid ……Is not heardIs not heard
HeardHeard ……Is not understoodIs not understood
UnderstoodUnderstood ……Is not done !Is not done !
This is true for Sender and Receiver !This is true for Sender and Receiver !
Closed loop Closed loop communicationcommunication
Une Une éétude rtude r éétrospectivetrospective
�� Retrospective cohort studyRetrospective cohort study–– All new born singleton from 1998 to 2003 All new born singleton from 1998 to 2003
�� In 2000 teaching Intervention: In 2000 teaching Intervention: –– 1 annual day multidisciplinary training1 annual day multidisciplinary training–– Didactic + interactive (CTG, EFM guidelines, case bas e Didactic + interactive (CTG, EFM guidelines, case bas e
discussion)discussion)–– HandsHands --on sessions : 6 scenarios on sessions : 6 scenarios (Shoulder (Shoulder dystociadystocia , PPH, , PPH,
EclampsiaEclampsia , Twins, Breech, Adult and neonatal resuscitation), Twins, Breech, Adult and neonatal resuscitation)
�� Outcome measures (preOutcome measures (pre --post intervention): post intervention): –– APGAR score at 5APGAR score at 5 ’’ ≤≤ 66–– Neonatal HypoxicNeonatal Hypoxic --ischeamicischeamic --encephalopathy (HIE)encephalopathy (HIE)
BJOG 2006
Results
0.53 (0.240.53 (0.24––1.13)1.13)11 (10.0)11 (10.0)16 (19.0)16 (19.0)Mod /severe HIEMod /severe HIEnn (rate/10,000)(rate/10,000)
0.50 (0.260.50 (0.26––0.95)0.95)15 (13.6)15 (13.6)23 (27.3)23 (27.3)HIEHIEnn (rate / 10,000)(rate / 10,000)
0.51 (0.350.51 (0.35––0.74)0.74)49 (44.4)49 (44.4)73 (86.6)73 (86.6)55’’ ApgarApgar ≤≤ 6, 6, nn (rate / 10,000)(rate / 10,000)
Relative Relative riskrisk20012001––2003 2003 ((nn= 11,030)= 11,030)
19981998––1999 1999 ((nn= 8430)= 8430)
Plan
�� What is simulation ?What is simulation ?
�� Why should we use simulation training ?Why should we use simulation training ?
�� Challenges in obstetric anesthesiaChallenges in obstetric anesthesia
�� Simulation in obstetric anesthesiaSimulation in obstetric anesthesia
�� ConclusionsConclusions
Conclusions : Simulation in obstetric anesthesia …
�� is a useful educational techniqueis a useful educational technique
�� can be used to teach procedural and noncan be used to teach procedural and non --technical skillstechnical skills
�� is a promising tool to foster teamwork and communicati onis a promising tool to foster teamwork and communicati on
�� its use needs to be tailored according to:its use needs to be tailored according to:
–– Learning objectivesLearning objectives
–– The level of training of the participantsThe level of training of the participants
�� needs to be integrated in a broader curriculumneeds to be integrated in a broader curriculum
�� to fulfill these objectives, we need :to fulfill these objectives, we need :
–– Development of regional/national network Development of regional/national network
–– Support from our specialty societySupport from our specialty society ……
Thank you for your attention !Thank you for your attention !
http://simulationmedicale.hughttp://simulationmedicale.hug --ge.ch/ge.ch/