title: Multidisciplinary In Situ Simulation-Based Training as a Postpartum Hemorrhage Quality Improvement Project.
abstract: Postpartum hemorrhage is a common obstetric emergency affecting 3 to 5% of deliveries, with significant maternal morbidity and mortality. Effective management of postpartum hemorrhage requires strong teamwork and collaboration. We completed a multidisciplinary in situ postpartum hemorrhage simulation training exercise with structured team debriefing to evaluate hospital protocols, team performance, operational readiness, and real-time identification of system improvements. Our objective was to assess participant comfort with managing obstetric hemorrhage following our multidisciplinary in situ simulation training exercise.
  
  
  
  This was a quality improvement project that utilized a comprehensive multidisciplinary in situ postpartum hemorrhage simulation exercise. Participants from the Departments of Obstetrics and Gynecology, Anesthesia, Nursing, Pediatrics, and Transfusion Services completed the training exercise in 16 scenarios run over 2 days. The intervention was a high fidelity, multidisciplinary in situ simulation training to evaluate hospital protocols, team performance, operational readiness, and system improvements. Structured debriefing was conducted with the participants to discuss communication and team functioning. Our main outcome measure was participant self-reported comfort levels for managing postpartum hemorrhage before and after simulation training. A 5-point Likert scale (1 being very uncomfortable and 5 being very comfortable) was used to measure participant comfort. A paired t test was used to assess differences in participant responses before and after the simulation exercise. We also measured the time to prepare simulated blood products and followed the number of postpartum hemorrhage cases before and after the simulation exercise.
  
  
  
  We trained 113 health care professionals including obstetricians, midwives, residents, anesthesiologists, nurse anesthetists, nurses, and medical assistants. Participants reported a higher comfort level in managing obstetric emergencies and postpartum hemorrhage after simulation training compared to before training. For managing hypertensive emergencies, the post-training mean score was 4.14 compared to a pretraining mean score of 3.88 (p = 0.01, 95% confidence interval [CI] = 0.06-0.47). For shoulder dystocia, the post-training mean score was 4.29 compared to a pretraining mean score of 3.66 (p = 0.001, 95% CI = 0.41-0.88). For postpartum hemorrhage, the post-training mean score was 4.35 compared to pretraining mean score of 3.86 (p = 0.001, 95% CI = 0.36-0.63). We also observed a decrease in the time to prepare simulated blood products over the course of the simulation, and a decreasing trend of postpartum hemorrhage cases, which continued after initiating the postpartum hemorrhage simulation exercise.
  
  
  
  Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Comprehensive hemorrhage protocols have been shown to improve outcomes related to postpartum hemorrhage, and a critical component in these processes include communication, teamwork, and team-based practice/simulation. As medicine becomes increasingly complex, the ability to practice in a safe setting is ever more critical, especially for low-volume, high-stakes events such as postpartum hemorrhage. These events require well-functioning teams and systems coupled with rapid assessment and appropriate clinical action to ensure best patient outcomes. We have shown that a multidisciplinary in situ simulation exercise improves self-reported comfort with managing obstetric emergencies, and is a safe and effective way to practice skills and improve systems processes in the health care setting.
authors.affiliation: Department of Obstetrics and Gynecology, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
authors.forename: Monica A
authors.initials: MA
authors.lastname: Lutgendorf
authors.affiliation: Department of Medical Simulation, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
authors.forename: Carmen
authors.initials: C
authors.lastname: Spalding
authors.affiliation: Department of Nursing, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Drake
authors.affiliation: Department of Anesthesia, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
authors.forename: Dennis
authors.initials: D
authors.lastname: Spence
authors.affiliation: Department of Obstetrics and Gynecology, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
authors.forename: Jason O
authors.initials: JO
authors.lastname: Heaton
authors.affiliation: Department of Obstetrics and Gynecology, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
authors.forename: Kristina V
authors.initials: KV
authors.lastname: Morocco
mesh_terms: D000072077:Anesthetists / Q000706:statistics & numerical data; D001771:Blood Banks / Q000592:standards / Q000706:statistics & numerical data; D001803:Blood Transfusion / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D002983:Clinical Competence / Q000592:standards* / Q000706:statistics & numerical data; D004634:Emergency Medical Technicians / Q000706:statistics & numerical data; D005260:Female; D006282:Health Personnel / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D033183:Interdisciplinary Communication; D008880:Midwifery / Q000706:statistics & numerical data; D007744:Obstetric Labor Complications / Q000628:therapy; D009773:Obstetric Nursing / Q000706:statistics & numerical data; D009774:Obstetrics / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000592:standards / Q000706:statistics & numerical data; D061214:Patient Safety; D016544:Patient Simulation; D006473:Postpartum Hemorrhage / Q000628:therapy*; D011247:Pregnancy; D015397:Program Evaluation / Q000379:methods / Q000706:statistics & numerical data; D058996:Quality Improvement; D013663:Teaching / Q000592:standards* / Q000706:statistics & numerical data; D000078329:Workforce; D000094902:Blood Banking / Q000379:methods