title: Simulation as a new tool to establish benchmark outcome measures in obstetrics.
abstract: BACKGROUND
  There are not enough clinical data from rare critical events to calculate statistics to decide if the management of actual events might be below what could reasonably be expected (i.e. was an outlier).
  
  
  OBJECTIVE
  In this project we used simulation to describe the distribution of management times as an approach to decide if the management of a simulated obstetrical crisis scenario could be considered an outlier.
  
  
  METHODS
  Twelve obstetrical teams managed 4 scenarios that were previously developed. Relevant outcome variables were defined by expert consensus. The distribution of the response times from the teams who performed the respective intervention was graphically displayed and median and quartiles calculated using rank order statistics.
  
  
  RESULTS
  Only 7 of the 12 teams performed chest compressions during the arrest following the 'cannot intubate/cannot ventilate' scenario. All other outcome measures were performed by at least 11 of the 12 teams. Calculation of medians and quartiles with 95% CI was possible for all outcomes. Confidence intervals, given the small sample size, were large.
  
  
  CONCLUSIONS
  We demonstrated the use of simulation to calculate quantiles for management times of critical event. This approach could assist in deciding if a given performance could be considered normal and also point to aspects of care that seem to pose particular challenges as evidenced by a large number of teams not performing the expected maneuver. However sufficiently large sample sizes (i.e. from a national data base) will be required to calculate acceptable confidence intervals and to establish actual tolerance limits.
authors.affiliation: Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Matt M
authors.initials: MM
authors.lastname: Kurrek
authors.affiliation: Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Pamela
authors.initials: P
authors.lastname: Morgan
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America.
authors.forename: Steven
authors.initials: S
authors.lastname: Howard
authors.affiliation: Department of Anesthesia and Critical Care, University of Wuerzburg, Wuerzburg, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Kranke
authors.affiliation: Division of Critical Care, Department of Pediatrics, University of Louisville, Louisville, Kentucky, United States of America.
authors.forename: Aaron
authors.initials: A
authors.lastname: Calhoun
authors.affiliation: Department of Emergency Medicine, University of California Los Angeles and Olive View-UCLA Medical Center, Los Angeles, California, United States of America.
authors.forename: Joshua
authors.initials: J
authors.lastname: Hui
authors.affiliation: Department of Research Design and Biostatistics, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Alex
authors.initials: A
authors.lastname: Kiss
mesh_terms: D019985:Benchmarking / Q000379:methods; D002983:Clinical Competence; D006801:Humans; D009774:Obstetrics / Q000193:education / Q000592:standards*; D017063:Outcome Assessment, Health Care