A clearly worried group of health care providers and a family member had gathered around the woman’s bedside. She was in labor and having pain at the incision site of her previous C-section — a sign that attempting a vaginal delivery might rupture her uterus. Meanwhile, the slow thud of the fetal heart monitor warned that the baby needed help. Without another C-section, the impending birth would almost certainly go wrong for both mother and child. Although neither the anguished woman nor her husband spoke much English, they both understood the term “C-section” and they were adamant. “No C-section,” she insisted and her terrified husband agreed. “No surgery,” he said. The interpreter requested earlier hadn’t appeared and no one on the medical team thought to request interpreter help by phone as they struggled without success to convey the urgency of the situation.

The labor and delivery nurse tried to relieve the baby’s distress by turning the woman on her side, administering oxygen and increasing intravenous fluids, to no avail. Minutes ticked by and the couple still said “No.” At last, the interpreter appeared. Finally understanding the dire need, the woman consented to surgery. The anesthesiologist and other operating room staff were mobilized but time was very short. The woman’s uterus had ruptured and events threatened to overtake the team as the patient was rushed to the OR for an emergency C-section. The physician asked for blood products but the order wasn’t directed to anyone in particular and, in the chaos, no one acted until the patient began to hemorrhage. At last a limp infant was delivered by cesarean requiring resuscitation; the new mother had to undergo a hysterectomy.

Sound real enough? That’s precisely the idea but this desperate scene was actually a training exercise, one of 10 simulated perinatal emergencies enacted at Fairview Southdale Hospital in Edina, Minnesota, between January and May 2006. The project was inspired by a 2004 report by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) estimating that 72 percent of perinatal sentinel events — incidents creating serious patient harm or the potential for serious harm — are rooted in communication breakdowns. Studies have shown that the incidents often begin with a series of “near misses” — lost opportunities to prevent later harm.  When the report appeared, Kristi Miller, RN, Clinical Nurse Specialist in Fairview’s obstetrics department began discussing ways to improve staff communication skills with Alison Page, the hospital’s VP for Patient Safety. Then, in 2005, Stan Davis, MD, joined Fairview Southdale’s obstetrics department, called The Birthplace, as a medical quality consultant. He and Miller attended a presentation on Perinatal Safety and Critical Event Team Training organized by Kaiser Permanente, one of the country’s leading health care providers. “That’s when the idea of rehearsing the circumstances that can lead to near misses as a way to head off critical failures began to come together,” says Miller. 

With R&D support from the 398-bed community hospital’s parent company, Fairview Health System, and the University of Minnesota School of Public Health, an interdisciplinary steering team designed the pilot project, co-chaired by Miller and Davis. The team focused on stressful scenarios likely to be complicated by distractions and emotional triggers. Besides the frightened couple, other fraught circumstances included maternal drug abuse, patient allergies, and the absence of vital equipment, patient records or critical personnel. The near misses uncovered ranged from non-use of sterile masks to lack of required consent forms. But the most prevalent problems were the communication lapses such as physicians so intent on fetal monitoring that they ignored input from support staff, directed critical orders toward no one in particular, and failed to fully inform patients about the critical situation for fear of alarming them. 

It’s too soon to know whether the simulation drills will improve patient safety at Fairview Southdale but the initiative has already impressed experts. “Drills are an excellent way to raise consciousness,” says Sue Gullo, MS, RN, a director at the Institute for Healthcare Improvement (IHI). “Professionals who are certain they would do all the right things in an emergency often learn that this just isn’t true. That experience motivates and inspires them to learn how to do better.” Doing the right thing every time even under stress is one of the goals of IHI’s Idealized Design model. Using the principles of reliability science, the model aims to help hospitals redesign systems of care to perform substantially better in the future than the best current performance. Idealized Design of Perinatal Care, the fourth Idealized Design model developed by IHI, has four components:

• Reliable clinical processes to manage labor and delivery
• Prevention, detection, and mitigation of errors
• Care teams that communicate effectively with one another and with patients and families
• Mother and family as the locus of control during labor and delivery

In February 2005, in association with Ascension Health, the nation's largest Catholic and largest nonprofit health system, and Premier, Inc., an alliance of not-for-profit hospitals focused on improvement, risk management, and purchasing, IHI launched the Perinatal Innovation Community — focused on idealized design. Fairview Southdale joined the community in the fall of 2005. “We think Fairview’s simulations fit in perfectly with the goals of ideal design,” says Gullo, who now heads the latest 32 hospital learning initiative, Improving Perinatal Care, as part of IHI’s IMPACT Network. “We hope to include Fairview staff as guest faculty in future training sessions.”

Highly realistic training exercises are not new, says Bill Riley, PhD, Associate Dean of the University of Minnesota School of Public Health, which helped sponsor the research for Fairview’s simulations. “The aviation industry has used flight simulators to train pilots for decades. The point is not to improve their technical skills, which are already top-notch, but their instinctive ones — the human factors.” More recently, medical education has turned to simulations, rather than actual patient encounters, to train surgeons and others, focusing especially on communication skills and sound judgment to better manage unexpected events and to prevent a bad situation from getting worse. The advantage of simulations is that errors of technique or judgment don’t expose real people to harm and trainees to shame and guilt. The disadvantage is that simulations rarely pack the same learning punch as live exercises, particularly when they occur in a classroom or lab.

“That’s why we conducted ours right on the unit,” says Fairview’s Davis, “to give the experience as much high fidelity as possible.” Training was not mandatory; all participants were volunteers. The mock adult patient was occasionally a mannequin (the newborn, always so), but more often the patient and “family members” were employees from elsewhere in the hospital who had been coached on what behaviors to simulate. The other 15 to 25 participants in each simulation exercise were the actual obstetricians, nurses, scrub technicians, orderlies, and others who work on the unit and in support services such as the lab and blood bank. They were not told in advance what the scenario would be. Their task was to fulfill their roles as high-pressure events unfolded around them. To heighten verisimilitude, equipment such as the fetal monitor was rigged to give alarm readings.

Each one-hour simulation was videotaped and afterwards, participants sat down for a viewing and discussion with the training’s developers. “This was really the main event,” notes Davis, “The simulations were primarily a catalyst for analysis.” During the approximately two-hour discussions, participants were encouraged to comment on their own and the team’s performance, sharing insights and lessons learned. Across all 10 simulations, near misses in patient care were identified an average of 19.2 times per exercise (see table below) but defensiveness or embarrassment was rare. Davis says, “It was such a non-threatening, non-risky environment that everyone was eager to offer and accept constructive comments.” Not that everyone always agreed on what needed improvement or how to improve. “But that debate was generally constructive, too,” he says.

Buzz about the project spread quickly throughout the unit, says Kristi  Miller. “We were flooded with emailed ideas for improvement, even from people who didn’t participate.” One suggestion: different color hats to identify ambiguous staff roles in emergency situations where medical personnel might not know each other.

Davis and Miller are hopeful that the favorable early reactions to the simulation exercises will encourage even more interest at Fairview Southdale when the project is repeated, probably in 2007. (The interdisciplinary team continues to monitor the project and the rollout to five other Fairview Health System hospitals began in June 2006). Roughly 35 percent of the 220-person Birthplace staff volunteered to participate in at least one scenario, including nine of the unit’s 93 obstetricians, three of its 14 anesthesiologists, and one of its eight neonatologists. While some physicians may have been unwilling to take unpaid time away from their private practices, Davis thinks another factor may have held them back. “Physicians are sometimes afraid to be challenged,” he says, “but we think that the word is out now that there’s nothing to be afraid of.” And there may be other incentives to physician participation down the road, he adds. “Contracts with the hospital are being renegotiated. There may be some stipulations involved.”

Kathy Connolly, RN, MSEd, CPHRM, Assistant VP for Risk Management at Premier Insurance Management Services (PIMS) in Charlotte, North Carolina, points out that a dividend from this team effort is improved patient safety and a decrease in harm which should appeal to physicians in a high-risk specialty such as obstetrics. “Although Fairview Southdale’s parent company, Fairview Health Systems, self-insures for a certain amount of claims at the front-end, it is part of an excess medical malpractice risk retention program that PIMS manages.” Nationwide, dollars paid for birth injury claims are greater than claims in other specialties, says Connolly, and premiums have followed as well. “Rehearsing for the worst cases helps a medical team develop the habits they need to rely on in real emergencies — automatic reactions such as the right priorities, unambiguous communication, and absolute teamwork.” Over time, says Connolly, realistic drills convert individual mentalities to group mentalities and “that takes competence to a whole new level.”

Drills can even benefit a hospital when a bad outcome is not averted and a lawsuit results, says Connolly. “One of the questions plaintiffs’ lawyers often ask is ‘did the hospital provide any training for emergencies?’ We prefer that our insureds be able to say yes.”

08/08/2006