Keywords
communication - health care professionals - labor and delivery - simulation
Labor and delivery (L&D) units are acute care units where life's most joyful moments
transpire, but unfortunately, they are not immune to adverse and sometimes tragic
outcomes. A 2004 Sentinel Event Alert published online by the Joint Commission indicated
that communication errors in the delivery room were the primary root cause of 72%
of the neonatal deaths and long-term neurologic morbidity reported to that agency.[1]
[2]
Extensive research and development in the area of medical team communication has led
to the development of TeamSTEPPS and similar training programs based on strategies
originally developed for commercial aviation and other high-risk industries (e.g.,
Crew Resource Management).[3]
[4]
[5]
[6]
[7] These tools have provided a roadmap for improving team communication with the use
of check backs and closed loop techniques.
However, despite this progress in strategies to improve health care team performance,
the etiology of gaps in teamwork and communication in acute situations similar to
those that occur in L&D units are not well known. The objective of this study was
to use simulated scenarios to identify common lapses in communication during high-risk
scenarios in the L&D setting by exploring the types and frequency of questions asked
during such scenarios.
Methods
The setting of this study was a L&D unit at a tertiary care obstetric center (Lucile
Packard Children's Hospital Stanford, Stanford, CA). As part of ongoing continuing
education and quality improvement, a multidisciplinary team of health care professionals
(HCPs) participated in routine simulation exercises in situ (in the actual L&D setting
where patient care occurs), using a sophisticated human patient simulator (Noelle,
Gaumard) in scenarios conducted by HCPs skilled in the use of simulation.
The teams of subjects consisted of four to five L&D nurses, one obstetric technician,
one to two anesthesiologists, and two obstetricians. All participants were at a minimal
level postgraduate year 3 or greater for residents and all the L&D nurses and technicians
had experience on L&D. No students were involved. Simulated clinical scenarios have
been embedded in team training in this L&D unit since 2004; thus, the majority of
participants have experienced a minimum of 2 to 3 years of biannual simulation-based
learning opportunities.
A series of simulated clinical scenarios involving three common obstetric emergencies
were utilized in this study: (1) postpartum hemorrhage (PPH); (2) maternal code/cardiorespiratory
arrest; and (3) severe preeclampsia. Each scenario lasted approximately 15 to 20 minutes.
Participants were instructed to perform all the usual actions including calling for
additional staff. The simulation team responded to all requests and provided the equipment
or services in the usual time frame as in a real event. The goal of video review was
to evaluate the questions asked during scenarios, specifically, (1) which questions
were asked across multiple scenarios and (2) which questions were repeatedly asked
within the same scenario. One investigator reviewed all of the videos, with initial
guidance and review of scenarios from two of the other investigators. Only questions
in which the HCP asking the question did not know the answer to the question were
considered. Thus, rhetorical questions were not counted for the analysis.
The obstetric simulations evaluated for this study were a routine aspect of quality
assurance and quality improvement at our institution and no human subjects could be
harmed. The research protocol was considered as exempt by the Stanford University
Institutional Review Board.
Results
A total of 27 simulations were conducted and reviewed, with 9 each of PPH, maternal
cardiorespiratory arrest, and severe preeclampsia. There were similar numbers of total
questions and questions repeated across the three scenario types, with maternal arrest
eliciting the most questions ([Table 1]). The median number of questions asked during a simulation scenario was 27 across
all scenarios.
Table 1
Prevalence of repeated questions within obstetric simulations
|
Clinical scenario
|
N (simulations)
|
Median number of questions asked (interquartile range)
|
Median number of repeated questions (interquartile range)
|
Percentage of questions that were repeated per scenario (interquartile range)
|
|
Postpartum hemorrhage
|
9
|
22 (19–23)
|
7 (4–9)
|
28% (24–42%)
|
|
Maternal code
|
9
|
35 (28–37)
|
9 (4–14)
|
29% (14–35%)
|
|
Preeclampsia
|
9
|
27 (20–31)
|
8 (4–11)
|
33% (27–35%)
|
|
All combined
|
27
|
27 (20–35)
|
8 (4–11)
|
30% (19–39%)
|
The types of questions asked during scenarios were often specific to the clinical
circumstance. However, there were some questions that were common across scenarios
([Table 2]). For example, “Has someone called anesthesiologist?” was asked in 78% of PPH scenarios
and 100% of preeclampsia scenarios. The question was also commonly repeated within
the same scenario in both of those clinical conditions. Similarly, the question of
whether a pediatrician or neonatologist was called was commonly asked in both the
maternal arrest and preeclampsia scenarios.
Table 2
Most common questions asked during multiple obstetric simulations
|
Question
|
PPH
N = 9
|
Maternal code
N = 9
|
Preeclampsia
N = 9
|
|
Personnel
|
|
Has someone called anesthesiologist?
|
7 (78%)
|
|
9 (100%)
|
|
Has someone called pediatrician/NICU nurse?
|
|
9 (100%)
|
5 (56%)
|
|
Have we called/can you call a code (for help)?
|
|
8 (89%)
|
|
|
Is someone timing/keeping record?
|
|
7 (78%)
|
|
|
Equipment
|
|
Do you have an epidural?
|
6 (67%)
|
|
|
|
Have we called for a PPH kit?
|
5 (56%)
|
|
|
|
Can we start another IV?
|
4 (44%)
|
|
|
|
Can we have an intrauterine tamponade device?
|
4 (44%)
|
|
|
|
Has a Foley been placed/Is the Foley in?
|
|
7 (78%)
|
|
|
[Where is the] crash cart?
|
|
6 (67%)
|
|
|
Clinical information—dynamic
|
|
Is the placenta still in/has the placenta delivered?
|
6 (67%)
|
|
|
|
What is the estimated blood loss?
|
5 (56%)
|
|
|
|
How long ago was the child born/what was the delivery time?
|
5 (56%)
|
|
|
|
Bleeding/hypertension during the delivery?
|
3 (33%)
|
|
4 (44%)
|
|
Are there contractions?
|
|
|
6 (67%)
|
|
Is there fever?
|
|
|
2 (22%)
|
|
Clinical information—static
|
|
History of high blood pressure?
|
|
|
9 (100%)
|
|
Problems with vision?
|
|
|
7 (78%)
|
|
Gestational age?
|
|
|
7 (78%)
|
|
Is this their first infant?
|
|
|
4 (44%)
|
|
When did the stomach pain start?
|
|
|
2 (22%)
|
Abbreviations: IV, intravenous; NICU, neonatal intensive care unit; PPH, postpartum
hemorrhage.
Aside from questions regarding personnel, clinical questions were asked about the
mother's history (gestational age, history of high blood pressure) as well as dynamic
questions about ongoing care in terms of therapies provided and current status of
the mother.
Some questions were asked in a repeated fashion within the same scenario ([Table 3]). In particular, questions regarding the status of personnel tended to be repeated.
For example, “Has someone called anesthesiologist?” was asked multiple times within
the same scenario in 43% of PPH scenarios, and “Has someone called pediatrician/neonatal
intensive care unit nurse?” was repeatedly asked in 56% of maternal code and 40% of
preeclampsia scenarios ([Table 3]).
Table 3
Questions repeated during obstetric simulations within the same episode
|
Question
|
PPH
|
Maternal code
|
Preeclampsia
|
|
Personnel
|
|
Has someone called anesthesiologist?
|
3/7 (43%)
|
|
4/9 (44%)
|
|
Has someone called pediatrician/NICU nurse?
|
|
5/9 (56%)
|
2/5 (40%)
|
|
Have we called/can you call a code (for help)?
|
|
5/8 (63%)
|
|
|
Is someone timing/keeping record?
|
|
1/7 (14%)
|
|
|
Equipment
|
|
Do you have an epidural?
|
1/6 (17%)
|
|
|
|
Have we called for a PPH kit?
|
3/5 (60%)
|
|
|
|
Can we start another IV?
|
3/4 (75%)
|
|
|
|
Can we have an intrauterine tamponade device?
|
1/4 (25%)
|
|
|
|
Has a Foley been placed/is the Foley in?
|
|
3/7 (43%)
|
|
|
[Where is the] crash cart?
|
|
3/5 (60%)
|
|
|
Clinical information—dynamic
|
|
Is the placenta still in/has the placenta delivered?
|
2/6 (33%)
|
|
|
|
What is the estimated blood loss?
|
1/5 (20%)
|
|
|
|
How long ago was the child born/what was the delivery time?
|
2/5 (40%)
|
|
|
|
Clinical information—static
|
|
History of high blood pressure?
|
|
|
3/8 (38%)
|
|
Gestational age?
|
|
|
2/4 (50%)
|
Abbreviations: IV, intravenous; NICU, neonatal intensive care unit; PPH, postpartum
hemorrhage.
Note: Number (percentage) of simulations when the question was repeated during the same
scenario. The denominator represents scenarios in which the question was asked at
least once.
Discussion
This study used videotaped simulated clinical scenarios to analyze the number and
types of requests for information among HCPs during obstetrical emergencies. Although
it is inevitable that questions would be asked during these emergencies, it is notable
that questions are often repeated in any individual clinical scenario. Furthermore,
we found that there were with identical requests for information being repeated across
all three simulated L&D emergency scenarios.
Three general categories of questions were noted across all of the clinical conditions
studied. The first category involved static medical information such as gestational
age and maternal history. The second category focused on dynamic medical information,
such as maternal clinical status, including but not limited to vital signs and estimated
blood loss. The third category of questions was focused on staffing/personnel resources.
Emergencies on L&D often involve multiple teams from different service lines (obstetrics,
anesthesia, and neonatology/pediatrics). Individual team members may be responding
from different areas of the hospital; therefore, the availability and presence of
personnel was a frequent question across clinical conditions, and sometimes repeated
within one simulated clinical scenario.
The strengths of our study include performance of all the simulations on the actual
L&D unit in which the teams rendered care (in situ simulations) rather than in a simulation
laboratory. Our teams were all experienced HCPs and intimately familiar with the location
of equipment, supplies, configurations of the rooms, and the additional resources
available. As a result, simulation artifact introduced by practicing scenarios in
foreign environments or with inexperienced HCP was not relevant in these scenarios.
Further, we used the same multidisciplinary teams that would be responding together
to these emergencies if an actual event were to occur, and all participants on the
team responded in the role that they occupy in actual practice. Other strengths of
the study are intrinsic to the use of simulation. Real-life events often do not lend
themselves to an in-depth review of team performance. However, video recorded simulated
events allow a repeated review and analysis of all actions and nonactions taken by
the team. Simulating clinical events also affords the opportunity to recreate extreme
and rarely experienced events for the HCP. By “stressing the system,” latent issues
that may not be transparent in less stressful situations may become transparent.
It is possible the repeating simulation scenarios could lead to improved communication
efficiency and result in decreased repeated questions. In this study, clinicians did
not participate in simulated scenarios repeatedly. The use of simulation and debriefing
could lead to improved communication for specific scenarios and for general care over
time.
This study has several limitations. Simulated clinical scenarios do not reflect actual
events with 100% fidelity. The questions asked in a simulated setting might not be
the only pertinent information needed in an actual clinical event. Simulated clinical
scenarios may not engender the same degree of physiologic and emotional stress to
the level that HCP experience when an actual patient's life is dependent on the care
given. Therefore, live clinical events need to be observed to confirm these data.
We cannot conclude from this study that repeated questioning would necessarily lead
to detrimental patient outcome; we cannot assume that asking for information at various
points in clinical care would diminish or improve care. However, improved communication
has been established as an important aspect of improving clinical care and patient
outcomes. Further, asking the same question unnecessarily is inefficient and potentially
precludes a more important question being asked at that same time.
We chose to evaluate three different clinical scenarios. One of our goals was to explore
the possibility that there is similar information needed by the team across multiple
emergencies. Once identified, that information could then be made readily available
during all crises. It is possible that evaluating more iterations of a single simulation
could have led to a more robust ability to formulate conclusions based on higher sample
size. We encourage other researchers to perform similar studies both in simulation
and in actual clinical care to add to our findings.
During an obstetric emergency, communication facilitates both a shared mental model
(what are we doing) and role clarity (who is doing it) between the multiple HCPs that
typically respond to such events. As described by Weller et al, “Shared mental models
lead to a common understanding of the situation, the plan for treatment and the roles
and tasks of the individuals in the team.”[8] Without a shared mental model, it is difficult to fully leverage all of the expertise
the team can provide. However, the use of concise, precise verbal communication during
crises is challenging.[9] This challenge in the health care setting was clearly demonstrated in this study.
Our teams asked a median of 27 questions per 20-minute simulated obstetric emergency—nearly
1.5 questions per minute. Nearly one-third of the questions was repeated at least
once; some were repeated multiple times. Many critical obstetric interventions require
more than 1 minute to complete; therefore, even the act of asking a relatively simple
and brief question could result in misallocation of attention by the HCP during the
task saturation that often occurs during a critical event. Further, many time-pressured
and high-risk events are characterized by auditory overload—particularly in the small
areas that normally comprise the patient care areas on L&D. Any questions asked by
the increasing number of multiple responders—regardless of importance—will contribute
to the high decibel level in the delivery room, making it even more difficult to hear
the answers. However, certain information is critical and must be shared, especially
as responders enter the room and during the acute treatment phase.
This study of simulated obstetric emergencies was able to identify several commonly
asked questions across all three emergency events. Defining the information that all
team members need to know and then assuring that they have that information in a timely
manner will facilitate care of the patient during not only an emergent obstetric event,
but any acute event which requires efficient team performance. The development of
a variety of modalities including focused team training in communication training
and interactive visual displays of key information may ultimately enable HCPs to provide
more efficient and effective care leading to optimal patient experiences and outcomes.
Future investigations should include prospective observations of live events for lapses
in verbal communication, creation of a visual display that is tailored to address
the observed lapses, and testing of the display in simulated and ultimately live settings.
