The Case

A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated prenatal care. A third-year obstetrics and gynecology resident delivered the infant under attending supervision via vacuum-assisted vaginal delivery. Following delivery of the shoulders, the resident turned to place the vacuum device on a nearby equipment stand. During that time window, the patient adjusted her positioning while on the birthing bed (creating an inadvertent push), and the infant slid out of the vaginal canal, slipped out of the resident’s hands, and dropped headfirst onto the floor.

The infant suffered a left parietal fracture and hematoma at the site of impact. Although he required close observation and neurosurgical consultation, no intervention was indicated. In reviewing the incident, staff interviews suggested that both noise and confusion of roles among the labor and delivery team contributed to the error, which, through luck alone, led to no long-term sequelae for the infant.

The Commentary

by Louis P. Halamek, MD

The delivery room can decompensate from a calm, controlled environment into utter chaos in a matter of seconds.(1) While the fetus is often the provocateur of such chaos, changes in the mother’s condition, equipment failure, or suboptimal provider performance can all play a role.

What is the source of the chaos in this case? Is it a lack of content knowledge or cognitive skill on the part of the physicians and nurses? Is it poor technical skills and coordination of manual activities on the part of the health care team? Or is it suboptimal coordination of another type—inadequate preparation and training, lack of a shared mental model, and poor communication? The attached video of a simulation performed in our center reveals the complex milieu of cues present during the resuscitation of a depressed neonate in the delivery room and illustrates the many cognitive, technical, and behavioral skills that are required to successfully care for patients in that domain.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a sentinel event alert in 2004 after receiving descriptions of 61 cases of perinatal death and 10 of permanent disability.(2) Root cause analyses identified communication problems as a contributing factor in 72% of the cases, making this the dominant cause of perinatal death and disability. Deficiencies in organizational culture (hierarchy and intimidation, failure to function as a team, and failure to follow the chain of communication) played a role in 55% of the cases. These findings indicate that the most frequently cited causes of sentinel events in the delivery room involve deficiencies in behavioral skills (eg, communication, leadership, and teamwork) rather than cognitive (content knowledge) or technical skills (manual dexterity and proficiency).

JCAHO issued several recommendations to health care organizations that care for pregnant women and newborns. The first two concern conducting team training, clinical drills, and debriefings. Let us consider how these recommendations can be implemented.

“Practice Makes Perfect…”

Although few would argue with the practical wisdom underlying this adage, the devil often lives in the details of who should practice, what should be practiced, how should practice occur, and when or how often should practice take place. Historically, health care professionals have trained by engaging in rigorous classroom activities followed by observing skilled practitioners before assuming graduated responsibility for independent practice, a model sometimes derisively referred to as “see one, do one, teach one.” Under this apprenticeship model, early training focuses on the acquisition of vast content knowledge. That initial knowledge is followed by training in pertinent technical skills. Unfortunately, this aspect of training is rarely standardized for content or the level of experience of the instructor.(3,4)

Simulation Training

High-fidelity simulation-based training offers an innovative learning approach compared to the traditional medical learning model.(5) Trainees are immersed in an environment that provides them with multiple realistic visual, auditory, and tactile cues, allowing them to effectively suspend their disbelief and perform as they would in the real environment. After their performance, they debrief with fellow trainees and expert instructors, watching the video record of their actions and discussing what went well, what did not go well, and what can be done to improve performance in the future. This methodology is based on decades of educational research revealing that adults learn by doing, not by listening or watching; this is especially true of technical (manual tasks) and behavioral (communication, teamwork, leadership) skills. High-fidelity, real-time, simulation-based training represents the standard for a number of industries, including aerospace, nuclear power, and national defense, where the risk to human life is high.

A number of educators and investigators have begun to question whether the traditional apprenticeship training model adequately prepares health care professionals to safely handle the life-threatening conditions that arise in their work. Does it make sense to “practice” patient care in the real environment where real consequences (to patients and those treating them) occur? Or should practice occur in a medical simulator on simulated patients with the threat of only simulated consequences?

How can health care organizations develop simulation-based training programs? Although a comprehensive description of the mechanics of establishing a simulation-based program is beyond the scope of this discussion, several general comments are in order.

Tailor the training to the needs of the trainee.
When using any methodology, one should first ask “What are the learning objectives?” Once objectives are defined, one should then consider the trainees and their unique learning style(s). One can then craft a program utilizing the learning methodology that optimally meets the needs of these adult trainees. As an example, assimilation of content knowledge may be most efficiently achieved by independent reading (journal, textbook, on-line source). However, when it comes to the acquisition and refinement of technical and behavioral skills (like those required by multidisciplinary obstetric and pediatric teams during post-delivery resuscitations), reading alone is insufficient. Rather, simulation-based training, first in a controlled medical simulator followed by drills in the real environment, is ideal.

Simulation-based training is not just for novices.
While novices certainly can acquire cognitive, technical, and behavioral skills in a simulator, experienced professionals also benefit. Other industries such as aviation require rigorous simulator activities on an annual (or more frequent) basis as a means of maintaining a high level of performance and safety. Regularly working through challenging scenarios with one’s colleagues in a realistic simulator, followed by constructive debriefing, should become a mandatory component of the health care professional’s ongoing development in the near future. This also promotes reliance on necessary teamwork that underlies such training efforts.

The key to simulation-based training lies in the methodology rather than the technology used for implementation.
Much attention has been paid to the sophisticated (and expensive—some more than $100,000) human patient simulators used for adult anesthesiology and critical care. Although the ability to realistically simulate patient anatomy and physiology is an important component of a high-fidelity simulated medical environment, it is not the only, nor, arguably, the most important, element of simulation-based training. Instead, the key lies in the learning methodology employed: immersion of trainees into challenging scenarios followed by constructive debriefings that discuss the cognitive, technical, and behavioral skills necessary for successful performance. The biggest mistake in developing a simulation-based program is to invest most resources into an expensive patient simulator while neglecting the other important components necessary for a successful program.

Successful suspension of disbelief is best achieved by providing as many visual, auditory, and tactile cues as possible.
A sophisticated human patient simulator is capable of providing numerous realistic cues to trainees. However, it is not by itself sufficient to create the sense of disbelief necessary for a successful learning experience. In addition to the patient, cues are provided by monitors, code carts, and other working medical equipment; fluids and drugs; professional colleagues who respond as they do in actual life; and other elements of the physical environment that make the simulator feel real. This is especially true for medical domains for which few or no realistic patient simulators exist. In our work in pediatric and obstetric simulation at the Center for Advanced Pediatric Education (http://www.cape.lpch.org), we have found that relatively simple and inexpensive mechanisms can be developed to overcome the limitations of the current generation of patient simulators. As an example, there is currently no true neonatal human patient simulator available on the market; all “infant” simulators are just that, designed with a size and features that portray a patient older than a newborn. Because the mannequins used do not have internal physiologic models and technologies that result in realistic heart tones and breath sounds, we use a handheld computer and an electronic interface that allows us to display realistic waveforms on a bedside monitor, effectively conveying the physiologic state of the neonate in real time. This eliminates the need for an instructor to continuously verbally describe the state of the neonate during a simulated resuscitation and adds tremendously to the ability of the trainee to suspend disbelief.

The most valuable component of a simulation program is its group of instructors.
Effective conduct of simulation-based training requires instructors who understand principles of adult education, appreciate the limitations of traditional educational methods, and seek to change the current system of medical training. Once identified, these instructors need to develop skills in identifying learning objectives for various target audiences, designing scenarios that reinforce these objectives, and facilitating constructive debriefings. Often, such skills can be best acquired by partnering with experienced simulation programs. Programs that offer instructor training may be found by accessing the Society for Medical Simulation Web site (http://www.socmedsim.org).

Establishing an effective and self-sufficient simulation program requires a broad base of support; doing so involves enlisting both leaders (ie, CEOs, board members) and potential trainees.
The most effective route to establishing and sustaining a robust simulation program is to enlist both top-down and bottom-up support. What does this mean? It is important to understand that even under the best of circumstances, change is often slow and difficult. Change in medical education and training certainly fits this description. It is also important to understand that resources (human, physical, and financial) will be required to effect change. Culture change and resource acquisition require the cooperation of those controlling people, space and money—typically department chairs and chief executive officers. An investment in the time needed to educate those in charge of such resources as to the benefits of simulation will be time well spent. One should endeavor to develop an implementation plan that is “win-win” and communicate that effectively—ie, explain in concrete terms how supporting such a program will benefit the department and the hospital.

Support should also be sought from those “in the trenches” of patient care. Help them to see how they will benefit from a new way of doing things. Conduct pilot training programs and offer them at no charge to those deemed as “thought leaders,” those who are influential both among their peers and among the institution’s leaders. These key trainees will serve as your advocates, testifying to the value of your training program and advocating for resource allocation on your behalf. They may also become founding members of your instructor staff.

Achieving a broad base of support is vital to sustaining a simulation program. First, the program should involve multiple disciplines, including medical and surgical specialties and subspecialties, nursing, pharmacy, respiratory therapy, and others. The more professionals that benefit from the program, the more support it is likely to engender, especially in the area of resource allocation. Second, the financial model should involve multiple sources of income, including tuition, fees, contracts, grants, and philanthropy. A growing endowment is the surest way to achieve long-term fiscal sustainability, and it protects your program as department chairs and hospital executives change.

Patient safety is an important issue at every health care institution in our country. Education and training are two of the keys to improving the performance of those carrying direct responsibility for patient care. Yet, too often, the approach to education and training is to “train as many as you can, as quickly as you can, as cheaply as you can.” Certainly this mantra is not in line with the tenets of adult learning. Simulation-based training is currently one of very few ways in which to effectively conduct multidisciplinary team training in high-risk domains. Professionals who understand the potential of this methodology, long used in other industries, to revolutionize medical training must take the lead in this effort now.

Implementing simulation-based training programs across medical domains and institutions will require collaborative research and development.
Designing a high-fidelity simulation-based training program that is grounded in adult learning theory and evidence-based medicine and can be disseminated widely is not a simple task. Although many independent efforts are under way around the world, more collaboration among investigators, hospital administrators, risk managers, industry, and national medical and patient safety organizations will be necessary to fully realize the potential of this methodology.

Whether or not simulation-based training in and of itself prevents incidents such as the ones described in this case, the goal of such training should be to equip providers with the skills required to perform their duties effectively and safely.

Take-Home Points

• In high-risk medical domains such as the delivery room, conditions may deteriorate rapidly and without warning, threatening the lives of patients. The most frequent contributing factor to these incidents is deficient behavioral skills.
• Simulation-based training, if effectively designed and implemented, is an excellent learning methodology for the practice of both behavioral and technical skills.
• Methods to educate and train future generations of health care professionals must evolve away from traditional lecture-based techniques and embrace new modalities in order to effectively teach patient safety competencies.

Louis P. Halamek, MD
Associate Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics
Director, Center for Advanced Pediatric Education
Director, Training Program in Neonatal-Perinatal Medicine
Stanford University

Dr. Halamek is the recipient of Agency for Healthcare Research and Quality (AHRQ) grant number 5U18HS012022 to study the effect of simulation-based training on performance in the delivery room.

References

1. Halamek LP. Improving performance, reducing error, and minimizing risk in the delivery room. In: Stevenson DK, Benitz WE, Sunshine P, eds. Fetal and Neonatal Brain Injury: Mechanisms, Management and the Risks of Practice. 3rd ed. Cambridge, England: Cambridge University Press; 2003:785-790.

2. Joint Commission on Accreditation of Healthcare Organizations. Preventing infant death and injury during delivery. Sentinel Event Alert. July 21, 2004; Issue 30. Available at: http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/print/sea_30.htm

3. Halamek LP, Kaegi DM. Who’s teaching neonatal resuscitation to housestaff? Results of a national survey. Pediatrics. 2001;107:249-255.
[ go to PubMed ]

4. Murphy AA, Halamek LP, Lyell DJ, Druzin ML. Training and competency assessment in electronic fetal monitoring: a national survey. Obstet Gynecol. 2003;101:1243-1248.
[ go to PubMed ]

5. Halamek LP, Kaegi DM, Gaba DM, et al. Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics. October 2000;106:e45.
[ go to PubMed ]

VIDEO

VIDEO: This 5-minute video shows a simulated post-delivery situation. A depressed neonate is being resuscitated after a delivery complicated by fetal blood loss. The providers of bedside care are all trainees with varying degrees of clinical experience enrolled in NeoSim, a simulation-based training program in neonatal resuscitation at the Center for Advanced Pediatric Education at Packard Children’s Hospital at Stanford. Pay attention to the multitude of visual, auditory, and tactile cues that are present in the simulated environment and the seriousness with which the trainees go about their tasks; these cues enable the trainees to effectively “suspend their disbelief” and behave as they would in real life. Note that it takes the team some time to establish effective communication and a clear chain of command. Compared to a commercial airline cockpit, the language used in the delivery room often is not standardized, important communications are rarely read back or confirmed, and a large number of distracters are present. All of these issues and more are reviewed during playback of the video during a constructive debriefing held immediately at the close of the scenario. Together with the instructors, the team of trainees discusses both the negative and positive aspects of their performance in a safe and nonjudgmental environment.
[Note: It may take several minutes for the video to begin playing.]

Video	Title	Length	View
1	Slippery Slide into Life	5:25	View Video