Enter the Matrix Enhancing Obstetrics Education Using Medical

Enter the Matrix: Enhancing Obstetrics Education Using Medical Simulation LTC Douglas Maurer, DO, MPH, FAAFP Carl R. Darnall Army Medical Center Family Medicine Residency

Learning Objectives Participants will discuss the evidence for and tenets of medical simulation n Participants will describe methods and techniques of incorporating simulation into resident obstetric curricula n Participants will practice running obstetric scenarios using high fidelity patient simulators n

Take Home Points n When you LIVE learning, you remember it! n The evidence supports OB simulation n Not as difficult or costly as you may think n Family Medicine programs should further incorporate simulation into their OB curricula

Why Simulation for OB? n 40% of maternal deaths preventable n Mistakes that can teach rather than harm n Planned experience of rare events… n …Limited duty hours n Experiential learning through activation n Meets ACGME core competencies n IT WORKS!!

ACGME Requirements

Read the ACGME tea leaves… n ACGME Bulletin, December 2005: n Clinical skills should be learned as far away from the patient as possible n Health care is one of the few industries that does not conduct routine rehearsals n Familiarity with protocols becomes clear during simulations “Simulation will be a part of the redesign of GME”

OB Simulation Evidence n Shoulder dystocia: n More rapid delivery (Deering, 2004) n Increased success rates (Crofts, 2006) n Retention at 6 and 12 mos (Crofts, 2007) n Decreased force applied and improved outcomes (Draycott, 2008) n Hypoxic encephalopathy decreased 50% n Brachial plexus injuries decreased 70%

OB Simulation Evidence n Postpartum hemorrhage: n Improved knowledge and performance (Birch, 2007, Ellis, 2008) n Improved timeliness in stopping hemorrhage and correct medications (Deering, 2009) n Error identification and improved management at 6 mos (Maslovitz 2007) n Tool to estimate blood loss (Bose, 2006)

OB Simulation Evidence n Instrument delivery: n High fidelity forceps model improved blade placement (Dupuis, 2006) n Vaginal breech delivery: n Improved breech delivery success in 8/12 safety markers (Deering, 2006) n Hopkins developed model for second twin deliveries (Ennen, 2010)

OB Simulation Evidence n Eclampsia: n Improved magnesium sulfate dosing and time to administration (Ellis, 2008) n Identified deficiencies in management (Thompson, 2008) n Cord Prolapse n Reduction in diagnosis-to-delivery interval and NICU admissions (Siassakos, 2009)

Family Medicine Simulation Curriculum

Quarterly Sim Days n Target specific areas n OB scenarios n Trauma / EM scenarios n Adult medicine / pediatric scenarios n Procedural hands-on n Intern orientation / on-call Incorporate sim with didactics n 1/2 day each during CME n Incorporate Team. STEPPS n

Mock Codes / CRM Monthly n Clinic and hospital n Residents, staff, nurses n Various scenarios n n Newborn (NRP / STABLE) n Child (PALS) n Adult (ACLS) / ATLS) n OB (ALSO) / MOES

OB Simulation Curriculum n OB OSCE / OB Sim Day n ALSO course n Perineal laceration workshop n CME series n Mock Codes / MOES

OB Curriculum Scenarios n n n Vacuum delivery Shoulder dystocia Post-partum hemorrhage Eclampsia 3 rd / 4 th degree laceration repair n n n Neonatal resuscitation Breech delivery Genetic counseling Sexual assault Electronic fetal monitoring

Would you like an example? LABOR AND DELIVERY NOLA, LA

Deep thoughts on… Simulation n How did you FEEL? n What went WELL with this simulation? n What could be done BETTER next time?

Our OB Simulators

NOELLE Birthing Simulator n Vacuum deliveries n Shoulder dystocia n Post-partum hemorrhage n Infant resuscitation n FHR monitoring n Eclampsia

Newborn HAL / Sim. New. B n Crisis resource management n Trauma training n Mock codes n Case-based didactics n Patient assessment

Episiotomy Trainer n Practice episiotomy technique n Contains all muscle layers n 1 st - 4 th degree repairs n Reusable

Pelvic Sonogram Trainer n Virtual reality pelvic ultrasound n Normal and abnormal US n 1 st – 3 rd trimester pregnancy n Ectopic pregnancy

OB Sim Practicum

Creating Your Own Medical Simulation Program Perform a needs assessment n Define goals n Secure simulation champions n Obtain support n Purchase equipment/designate space n Identify / train instructors n Develop the curriculum n Plan a rollout period n

Perform a Needs Assessment Must have a clear vision n Skills vs. team training n Where to start? n n Sentinel event n Root cause analysis n Staff / resident surveys n Direct observation

Secure Simulation Champs n Key personnel n FM leader n OB n Peds n Nurse education / patient safety n Senior nurse n Advocate, promote, assist, develop!

Obtain Support n Secure buy-in n Departmental n Institutional n Learners Program development n Learning goals / objectives n Availability / scheduling of staff n $$$ and space n

Purchase Equipment and Designate Space n Congruent with program goals n And $$$! One room vs. simulation center n Renovations!! n Permanent space vs. mobile? ? n

Indentify / Train Instructors Motivation is key!! n High fidelity vs. low fidelity n Involve key stakeholders n Grassroots vs. formal training n Train the trainers! n

Develop the Curriculum n Phase 1: Plan the overall curriculum n Define specific learning objectives n Program the simulator n Phase 2: Briefing and Debriefing n Limited number of objectives n “Take home messages” n Orient your learners n Don’t forget to debrief!!

Plan a Roll-Out Period Ensure you know what you are doing! n Secure all necessary equipment n Ensure adequate staffing n Curriculum must be complete n Get feedback after every event n

Sustainability Self-reflect on the past year n Share your successes n Reenergize and refocus your team n Recruit and expand your team n Always keep it fresh n

Lessons Learned n KISS: Keep It Simple, Stupid! n On-the-fly changes n Patient gets better, patient gets worse n Technology WILL fail! Roll with it! n Residents WILL have their own ideas n Residents WON’T think of basic stuff n MAKE IT REAL!

Take Home Points n When you LIVE learning, you remember it! n The evidence supports OB simulation n Not as difficult or costly as you may think n Family Medicine programs should further incorporate simulation into their OB curricula

Resources n n n FMDRL: http: //www. fmdrl. org/ Simulators: n NOELLE / Newborn HAL: http: //www. gaumard. com/ n Perineal laceration simulators: http: //limbsandthings. com/us/home/ Training: http: //www. harvardmedsim. org/center-for-medicalsimulation-ims. php Journals: http: //journals. lww. com/simulationinhealthcare/pages/default. aspx Team. STEPPS: http: //teamstepps. ahrq. gov/ Grants: http: //afmrd. org http: //ahrq. gov

Questions? Thank you!