A Simulation-Based Scenario to Help Prepare Learners in the Management of Obstetric Emergencies

The use of simulation-based training to develop, improve, and maintain clinical competencies is effective for clinicians at all levels of training.1–6 Simulation-based methods are especially ideal for interdisciplinary practice around rare or infrequent clinical events where practitioner performance is critical for preventing patient morbidity or mortality.7–9 These have difficult to measure outcomes because of the rarity of event occurrence. The aim of simulation-based training is to analyze performance during enactments of real-life patient scenarios, detect areas of deficiency or excess, and through immediate debriefing initiate performance improvements that will transfer to applied clinical practice.1,4–6 The relative rarity and unpredictability of obstetric emergencies makes it difficult to assess whether or not simulation acquired competencies can have an impact on subsequent clinical performance. The case presented herein recounts the results of an actual obstetric incident where the competencies practiced through simulation-based training were applied in the management of an actual obstetric and neonatal emergency. Simulation-Based Program We conducted a needs assessment focused on improving our system-level response to obstetrical emergencies at our institution, after several events where interdisciplinary communication between obstetrics, anesthesia, emergency medicine, and neonatology were identified as contributing factors to less than optimal patient management. We subsequently developed a curriculum to focus on the knowledge and skills required to manage an emergency event where the patient is pregnant, as well as the needs of her fetus. In addition to issues associated with clinical management, we emphasized the importance of communication between and within teams responding to an obstetric emergency. Research associated with evaluating the effects of this curriculum received an exemption after review from our Institutional Review Board. We constructed a library of 16 different case scenarios encompassing various patient presentation details and included multiple potential progressions dependent upon practical decision making. All scenarios were built around obstetric emergencies and were designed to require consultation from the participating specialty services (Obstetrics/Gynecology, Anesthesiology, Neonatology, and Emergency Medicine). We conducted weekly 2-hour simulation-based sessions over a 6-month period, with residents from all specialties participating in two or more sessions. We implemented postsimulation debriefing using similar standards to those proposed by Rudolph et al and further guided using the self-assessment instrument (Fig. 1).11,12 We assessed the program's effect on applied clinical behavior by tracking clinical data (case logs) associated with obstetric emergencies that presented at our institution during the year of the training program, including the details of the case, the clinical team, and the program-related training status of the clinical team members. The case presented herein includes a respiratory arrest case scenario. We present the details of the simulated case scenario and then present details about how training that incorporated this scenario prepared learners for an actual obstetric emergency of a related case.Figure 1.: Team-based self-assessment instrument used to stimulate reflection during debriefing.SIMULATION CASE INFORMATION Demographics Case Title: Respiratory Arrest in an Obstetrical Patient Patient Name: Noelle Casey Scenario Name: Treatment of respiratory arrest in a pregnant patient Simulation Developers: Pamela Andreatta, PhD; David Marzano, MD; Jennifer Frankel, MD; Sara Boblick Smith, MD; Alexandra Bullough, MD Simulator: NOELLE™ Date of Development: July 2009 Appropriate for the following learner groups: Residents: Postgraduate Year (PGY) 1, 2, 3, 4 Specialties: Obstetrics, Pediatrics, Emergency Medicine, Anesthesia Nursing: Obstetrics, Pediatrics, Emergency Medicine, Anesthesia Allied Health: Respiratory Therapists, Pharmacists CURRICULAR INFORMATION Educational Rationale Respiratory arrest is a rare event in the pregnant patient. Learning Objectives Accreditation Council for Graduate Medical Education General Competencies: Medical knowledge Identify risk factors for respiratory distress during pregnancy Describe physiologic changes that occur during pregnancy Describe signs and symptoms of a patient with worsening respiratory symptoms Describe a differential diagnosis for respiratory distress in a pregnant patient Patient care Demonstrate recognition and treatment of respiratory distress Demonstrate knowledge and appropriate use of interventions to treat respiratory distress Demonstrate recognition of the appropriate differences in the resuscitation of a pregnant patient Practice-based learning and improvement Discuss risk factors leading to respiratory arrest in a pregnant patient Discuss resuscitative maneuvers in a pregnant patient Discuss indications for delivery of the infant Interpersonal and communication skills Demonstrate team leadership Demonstrate appropriate communication skills during an emergency, ie, check backs Demonstrate ability to call for help when needed (Anesthesia, Obstetrics, Pediatrics) Professionalism Demonstrate teamwork and communications Demonstrate ability to effectively interact with patient, patient family, and other team members with respect Systems-based practice Demonstrate knowledge of care after the event Demonstrate ability to counsel patient/family Guided Study Questions What are common conditions that can lead to respiratory arrest in a pregnant patient? What are less common conditions? What are that normal physiologic changes in the respiratory system during pregnancy? What are appropriate changes in routine resuscitative efforts during pregnancy? When should delivery of the infant be considered? What other services would you call in this emergency? Preparation Noninvasive blood pressure cuff Three-lead Electrocardiogram (ECG) Pulse oximeter Several 16-gauge angiocatheters Endotracheal tube Laryngoscope 60-mL syringes Fetal monitor Heparin Tissue plasminogen activator (TPA) Intravenous (IV) fluids Setup Preparation time: 15 minutes Simulation: 30 minutes Debrief: 15 minutes CASE STEM Noelle Casey is a 34-year-old female who is 28 weeks pregnant with her second child (Gestation/Parity; G2P1) and presents to the Emergency Department for shortness of breath. The patient states she was feeling well earlier in the day but that she suddenly became short of breath while standing at the sink washing dishes. She had no similar problems previously. She states it feels as if she “can't get enough air.” Patient Data Background Noelle Casey is a 34-year-old female, G2P1, who presents to the Emergency Department complaining of shortness of breath. She reports that she was standing at the sink washing dishes when she suddenly became short of breath. She denies any previous similar problems. She says that she “can't get enough air.” It is worse with exertion. Her pregnancy has been uncomplicated thus far and she has received routine prenatal care. She denies any fever, chills, upper respiratory infection symptoms, chest pain, cough, or hemoptysis. She has mild swelling of her legs which is symmetric and has gradually worsened throughout her pregnancy. She denies recent travel. Further History From Patient's Relative on Request Surgical history: Appendectomy Medications: Prenatal vitamins Allergies: No known drug allergies (NKDA) Social history: Married, lives with husband and 2-year-old daughter Denies tobacco, alcohol, or drug use Family history: Negative Initial Vital Signs Vitals: temperature: 37.3°C, respiration rate: 28, heart rate: 120, blood pressure: 90/50, oxygen saturation: 83% on room air. Initial Physical Examination General: Pregnant female, pale and diaphoretic, anxious, in mild distress. Head, Eyes, Ears, Nose, and Throat (HEENT): Atraumatic, pupils equal round reactive to light (PERRL), oropharynx benign, moist mucous membranes. Neck: Supple, no lymphadenopathy. Lungs: Clear to auscultation bilaterally (CTAB). Heart: Tachycardic, regular, no murmurs. Abdomen: Positive bowel sounds. Gravid. Soft, nontender, no rebound or guarding. No hepatosplenomegaly (HSM). Extremities: 1+ Lower extremity edema, bilateral. Neurologic: Alert and oriented to person, place, and time; no focal sensory or motor deficits. Additional patient information and the progressive arms of the simulation-based scenario are described and presented in Table 1.Table 1: Simulated Patient Details and Progression SequencesAPPLICATION OF SKILLS IN CLINICAL CARE One obstetric emergency involving acute inflammatory demyelinating polyneuropathy (AIDP/Guillain-Barré) occurred at our institution during the period of evaluation following simulation-based training. Guillain-Barré is a rare neurologic disease with occurrence during pregnancy estimated at 0.75–2/100,000 per year.10 Clinical features include distal arm and leg paresthesias and areflexia, generalized limb weakness leading to paralysis affecting respiratory and deglutition muscles, and autonomic disturbances that can be life threatening (eg, hypo-/hypertension and cardiac arrhythmias). Approximately 13% of pregnant Guillain-Barré patients will die as a result of cardiac arrhythmias or pulmonary emboli. Pregnant patients with Guillain-Barré are typically hospitalized with approximately one-third requiring ventilatory support. Premature birth is associated with Guillain-Barré during pregnancy, usually by cesarean delivery. A 25-year-old pregnant patient was admitted at 23+5-week gestation to the obstetric service for shortness of breath and feet/hand/facial numbness. She was diagnosed with acute inflammatory demyelinating polyneuropathy (AIDP/Guillain-Barré) and transferred to the neurology service with continued close monitoring by the obstetric team. During her course, she developed headache, mildly elevated systolic blood pressure of 130, and mild proteinuria. She was transferred back to the obstetrical service and evaluated for pre-eclampsia. After a negative work-up, she was discharged to the acute rehabilitation floor to complete inpatient rehabilitation at 26+4-week gestation and was subsequently followed by physical medicine and rehabilitation with obstetric surveillance of fetal heart monitoring, obstetric assessment twice weekly and as needed for pregnancy-related concerns (ie, contractions and vaginal bleeding). At 30+2-week gestation, the patient began having contractions. A second-year obstetric resident evaluated her and found her cervix to be closed and contractions improved with catheterization of the bladder. The patient was placed on continuous fetal monitoring secondary to concern for these contractions. While on fetal monitoring, the patient had an aspiration event followed by hypoxia. The obstetric resident (who had participated in the training program) and several hospitalists (who had not) were at the bedside, and it was determined that the patient needed to be intubated (a component of her simulations training). After intubation, the patient experienced ventricular tachycardia, a code was called, and the advanced cardiac life support arrest protocol was initiated. The obstetric resident activated the “Birth Center” pager in addition to the code team page (a component of her simulations training), making sure to specify that the patient was coding and that supplies for a cesarean delivery and neonatal resuscitation should be brought to the room. The obstetric and neonatology teams (who had also participated in the simulation program) arrived to the room with surgical instruments and neonatal resuscitation supplies within 6 minutes (as taught in the simulation). The patient had been undergoing resuscitation for cardiac arrest for approximately 5 minutes with unsuccessful resuscitation. The program-trained team members responded by making the decision to evacuate the uterus to improve the effectiveness of the resuscitative efforts. A 1375-gram infant was delivered and successfully resuscitated with a 10 minutes of life Apgar score of 8 (points taken off for color and tone). The infant was placed under the warmer with a nasal cannula placed for supplemental oxygen and an orogastric tube placed to decompress the stomach. All aspects of the resuscitation were emphasized in the simulation-based case. The infant was transported to the neonatal intensive care unit for further management. Within 9 minutes of the emergency cesarean delivery, normal sinus rhythm was restored for the mother, she awakened, opened her eyes, was able to squeeze her right hand, and nod her head yes and no. She was sedated with fentanyl and midazolam for abdominal closure and transferred to surgical intensive care unit for further management. Both mother and infant were later discharged home in good condition. The accurate and timely responses of the clinicians who had completed the training program compared with those who had not, along with the level of clinical reasoning and decision making under extreme stress by a junior staff resident, the correctness of the junior staff's response, postevent interviews with other responding team members, and the departmental morbidity and mortality conference discussions in obstetrics & gynecology, anesthesiology, and pediatric neonatology, suggest that the participants were able to apply what was taught in a simulated environment to a similar case in a real patient care setting. COMMENT This case illustrates the need for obstetrical drills for rare clinical events and how those drills can prepare clinicians with the requisite knowledge and skills to adequately respond to an emergency. In this example, an extremely rare clinical event occurring in an unusual clinical setting presented a life-threatening emergency for both mother and fetus. Timing was critical to the outcome, and any delay in decision making could have potentially led to the loss of both patients. The second-year resident present at the time of the event had participated in comprehensive simulation-based team training drills involving obstetric emergencies, including the scenario presented in this report. She was able to rapidly assess the clinical situation, make an evidence-based decision to proceed with an emergency cesarean section (identifying the importance not only to the fetus but also the resuscitation of the mother), and executed her decision within 6 minutes. Other members, but not all, of the responding team had also participated in the training. Although even extraordinary clinical performance may result in a poor clinical outcome in insurmountable circumstances, and poor performance may result in a favorable clinical outcome, we believe that the training contributed to excellent clinical performance from the clinicians who completed the training and that the performance resulted in a favorable clinical outcome for the mother and infant. We also acknowledge that if there had been insuperable conditions, the patients' outcomes could have been adverse, despite the clinicians' excellent performance. Clinical simulation has become an instrumental teaching adjunct in many obstetrical training programs and has been endorsed by organizations such as the Institute of Medicine and American College of Obstetrics and Gynecology. In fact, anesthesiology has added simulations to their requirements for maintenance of certification and has recently made participation in simulated scenarios a Residency Review Committee requirement. Other specialties are likely to follow. Still, there are few data demonstrating the transfer of simulation-based performance directly to applied clinical performance in the management of an actual obstetric emergency. The real-life case presented here demonstrates that simulation scenarios can teach the key management points that may lead to an improvement in provider and team management of uncommon emergencies even when the specific emergency was not the one in which the learners participated in the simulation training. Although the clinical case of AIDP is not specifically practiced in our program, our respiratory arrest scenario has many similar clinical components that provided a foundation from which the learners could apply their instruction to a related but not identical case in real-life performance. It would be unpractical to design clinical scenarios for every clinical eventuality; however, we believe that in selectively creating cases with common clinical attributes to other potential conditions, we can provide learners with an armamentarium of clinical abilities from which to draw upon in applied clinical practice. Using real-life clinical events to develop simulation scenarios can help build a practical case library that facilitates the application of directly relevant clinical skills, in addition to providing evidence-based reference cases that emphasize the value of the simulation exercises to applied clinical practice during debriefing. Although clinical data demonstrating improved outcomes as a result of simulation-based training in rare clinical events will continue to be challenging to secure, we believe that this case report underscores the value of simulation-based methods for learning and maintaining clinical skills in the management of obstetric emergencies and other rare obstetric conditions. ACKNOWLEDGMENT The authors thank Alexandra Bullough, MD, Department of Anesthesiology, University of Michigan, for her help.