SMFM Papers - American Journal of Obstetrics & Gynecology

SMFM Papers

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Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training Nelli Fisher, MD; Lewis A. Eisen, MD; Jyothshna V. Bayya, MD; Alina Dulu, MD; Peter S. Bernstein, MD, MPH; Irwin R. Merkatz, MD; Dena Goffman, MD OBJECTIVE: To determine the impact of simulation-based maternal

RESULTS: Postintervention scores reflected statistically significant im-

cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff.

provement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P ⫽ .042) and cesarean delivery (240 vs 159 seconds, P ⫽ .017).

STUDY DESIGN: Maternal-Fetal Medicine staff (n ⫽ 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life suppport pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring.

CONCLUSION: Prompt cardiopulmonary resuscitation initiation and

pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for MaternalFetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event. Key words: maternal cardiac arrest, obstetric simulation training, simulation education

Cite this article as: Fisher N, Eisen LA, Bayya JV, et al. Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training. Am J Obstet Gynecol 2011;205:239.e1-5.

M

aternal cardiac arrest, a rare and devastating obstetric emergency, is on the rise from 1 in 30,000 pregnancies reported in 2002 to 1 in 20,000 as of 2005.1,2 Survival rates during maternal cardiac arrest have been shown to be worse compared with survival rates of other adults, with rates as low as 6.9%.3,4 As maternal age increases, obesity rates soar and the number of pregnancy-reFrom the Department of Obstetrics and Gynecology (Drs Fisher and Bayya), Maimonides Medical Center, Brooklyn, and the Division of Critical Care Medicine, Department of Medicine (Drs Eisen and Dulu), and the Department of Obstetrics and Gynecology and Women’s Health (Drs Bernstein, Merkatz, and Goffman), Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY. Presented as an abstract at the 31st Annual Meeting of the Society for Maternal-Fetal Medicine, San Francisco, CA, Feb. 7-12, 2011. Received March 11, 2011; revised May 2, 2011; accepted June 3, 2011. Reprints not available from the authors. The authors report no conflict of interest. 0002-9378/$36.00 Published by Mosby, Inc. doi: 10.1016/j.ajog.2011.06.012

lated complication rises, these events may become even more common. Timely initiation of uninterrupted, properly performed chest compressions is the most critical step in successful resuscitation, as emphasized in new advanced cardiac life support (ACLS) guidelines.5 Yet, critical care teams may not be available in the first few minutes of maternal code and on arrival, they may be less familiar with pregnancyrelated modifications. Thus the obstetric team must be prepared to promptly initiate cardiopulmonary resuscitation and share knowledge of pregnancy-specific modifications to resuscitative measures for successful outcome of mother and fetus. Among obstetric providers, the maternal-fetal medicine physician (MFM), often the first to initiate care of an unresponsive pregnant patient, may be also looked to as a consultant with crucial knowledge of pregnancy-related modifications to guide a resuscitation team. Current ACLS requirements and training are insufficient for sustaining resuscitation skills.6 In the field of internal medicine, compared with traditional cardiopulmonary resuscitation training, simulation-based education has been

demonstrated to be significantly more effective as a teaching tool and resulted in enhanced medical resident adherence to American Heart Association protocols during actual codes.7 Among obstetric providers substantial deficiencies in management of simulated maternal cardiac arrest were noted in the recent study by Lipman and colleagues.8 In obstetrics, no study has demonstrated the use of simulation for improving the management of a pregnant women who have had a cardiac arrest. We hypothesize that a simulation-based program for MFM staff will improve knowledge, confidence and performance in the management of cardiac arrest. Our primary objective was to determine the impact of a simulation-based maternal cardiac arrest educational program on postintervention performance, knowledge, and confidence of MFM staff at our institution.

M ATERIALS AND M ETHODS

MFM attendings (n ⫽ 12) and fellows (n ⫽ 7) at a large academic institution participated in a standardized maternal cardiac arrest simulation program, which consisted of preintervention, in-

SEPTEMBER 2011 American Journal of Obstetrics & Gynecology

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SMFM Papers FIGURE 1

Pregnancy modifications to cardiac arrest resuscitation9,10

Fisher. Simulation training for maternal cardiac arrest. Am J Obstet Gynecol 2011.

tervention, and postintervention maternal cardiac arrest simulations. The program was designed and implemented by an interdisciplinary team including 2 critical care medicine attendings, 2 MFM attendings, an MFM fellow, and a general obstetrician. Before simulation, each provider was oriented to the simulation set up and equipment. Participants were not aware of what scenario they would encounter before each simulation as we have an ongoing comprehensive obstetric simulation program. All data collected were deidentified. The intervention was developed after initial preintervention simulations identified deficiencies demonstrated by the participants. An intervention workshop consisted of an American Heart Association (AHA) basic life support session, ACLS didactic tailored to the management of pregnant women, followed by a simulation practice session. ACLS didactic was developed by an interdisciplinary team and was based on AHA guidelines. It consisted of review of basic rhythms producing pulselessness, recognition of shockable vs nonshockable rhythms, ACLS pulseless arrest algorithm, initial airway management steps, and cardiac arrest pregnancy modifications. The workshop concluded with a simulation practice session guided by immediate feedback. Postintervention simulations were conducted in 3 week intervals after the simulation-based workshop. Each pre- and postintervention simulation included a maternal cardiac arrest drill, a multiple choice test, and an attitudes/confidence survey, which were immediately followed by individualized debriefing session conducted by the MFM 239.e2

www.AJOG.org and critical care simulation team. The same clinical scenario was used for all simulations. Simulations took place in our fully stocked mock labor and delivery room. A high-fidelity simulator (NOELLE; Guamard Scientific, Coral Gables, FL) with capability to display maternal vital signs, cardiac rhythms, and continuous fetal monitoring was used for each simulation. All simulations were digitally recorded for debriefing, scoring, and timing of the events. The scenario started with a confederate nurse calling the MFM physician (trainee) to the mock labor and delivery room for an evaluation of an unresponsive full-term pregnant patient with fetal heart rate at approximately 60 beats per minute. In addition, nursing, resident, and respiratory staff were available to assist in performing tasks, but these staff members were confederate actors and were instructed to only perform tasks as requested by the trainee. If requested, cardiac monitoring displayed ventricular fibrillation. If no defibrillation was requested by 4 minutes, the rhythm changed to asystole, and if defibrillation was requested, after the shock was administered asystole ensued. After 8 minutes, the scenario ended with programmed maternal mortality. The multiple-choice test, administered immediately after each simulation, consisted of 9 questions focused on pregnancy-related modifications of cardiac arrest management. An attitudes and confidence survey was administered next, followed by individualized debriefing of trainee performance. Our checklist, developed by our interdisciplinary team, was used for debriefing and consisted of a maternal performance score (9 pregnancy-related modifications in the management of cardiac arrest; Figure 1) and a critical care performance score (16 tasks; Figure 2). The pregnancy modifications portion was based on AHA guidelines, part 10.8 (cardiac arrest associated with pregnancy),9 unchanged from 2010 guidelines10 (Figure 1). Sixteen critical care tasks were adopted from AHA guidelines, part 7.2 (management of cardiac arrest).11 Eleven initial airway management tasks included in the critical care performance portion of a checklist were

American Journal of Obstetrics & Gynecology SEPTEMBER 2011

FIGURE 2

Initial management of cardiac arrest: critical care tasks11,12

Fisher. Simulation training for maternal cardiac arrest. Am J Obstet Gynecol 2011.

previously validated (Figure 2).12 Response to the confidence question “ I feel confident in my ability to manage maternal code” was assessed based on a Likert scale from 0 to 7 (strongly disagree being 0 and strongly agree being 7). Maternal, critical care, and total performance median scores, as well as knowledge, confidence and timing to critical events were compared pre- and postintervention. Wilcoxon rank sum, Mann-Whitney U and Kruskal-Wallis tests were used for analysis. This study was approved by our institutional review board.

R ESULTS Nineteen MFM staff (12 attendings and 7 fellows) completed preintervention simulations, followed by intervention and subsequent postintervention simulations. Six of our providers had 20-30 years of experience since graduating from residency, 4 had 10-19 years, and 9 had less than 10 years of experience. Four (21%) MFM physicians previously had to be leaders during maternal code, with total of 8 codes led by these physicians. Eleven (58%) of MFM staff had participated in a maternal resuscitation in the past. Postintervention median scores demonstrated statistically significant improve-

SMFM Papers

www.AJOG.org ment in maternal, critical care and total performance as well as knowledge and confidence scores when compared with preintervention median scores (Table). MFM staff improved significantly in timely initiation of cardiopulmonary resuscitation (CPR) during postintervention simulations (median, 32 seconds vs 120 seconds; P ⫽ .042). In addition, 2 providers who failed to initiate CPR at the baseline simulation began chest compression within 32 seconds of maternal code during postintervention simulations. Timely consideration of cesarean delivery performance improved postintervention (median time, 159 seconds vs 240 seconds; P ⫽ .017). Although 3 providers did not consider delivery during baseline drills, at postintervention simulations, the same providers delivered the fetus within 5 minutes of cardiac arrest. Preintervention scores were not affected by years of experience, or an experience of participation or being a leader in an actual code. Postintervention, however, those with 10-19 and 20-30 years of experience compared with those with less than 10 years of experience performed statistically significantly better (median, 13.5 vs 17, 18; P ⫽ .013). Postintervention scores for those who had participated in a real cardiac arrest event in the past were significantly better than those who had not (median, 17 vs 13.5; P ⫽ .007).

C OMMENT We have demonstrated significant benefit of a simulation-based training program in improving MFM staff performance, knowledge, and confidence in the management of maternal cardiac arrest. Maternal cardiac arrest is an unexpected and infrequent emergency. Prompt initiation of appropriate CPR and the application of pregnancy modifications are crucial for survival of mother and fetus during a code. An MFM physician, a likely leader responsible for training labor and delivery members to be prepared for maternal code, and a possible first responder in this emergency, encounters these catastrophic events rarely.

TABLE

Comparison of pre- and postintervention performance, knowledge, and confidence scores Scores

Preintervention median (IQR)

Postintervention median (IQR)

Maternal performance (max 9)

2 (2–4)

7 (5–8)

.027

Critical care performance (max 16)

5 (3–6)

7 (7–8)

.027

Total performance (max 25)

7 (6–9)

14 (12–15)

.018

Knowledge (max 9)

6 (4–6)

8 (7–9)

.043

Confidence (max 7)

2 (1–3)

5 (3–5)

.001

P value

.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................

IQR, interquartile range; max, maximum score. Fisher. Simulation training for maternal cardiac arrest. Am J Obstet Gynecol 2011.

In addition, an MFM physician may be seen as a consultant with crucial knowledge of pregnancy modifications to guide an experienced resuscitation team. Simulation training provides an opportunity for MFM physicians to refresh their knowledge, to practice management of a rare devastating event and to increase confidence during maternal code management. Knowledge deficits, lack of confidence, and suboptimal performance at the time of baseline simulated maternal cardiac arrest among obstetric providers found in our study corroborates the findings in recent publications.8,13,14 After a simulation-based intervention tailored to correct our participants’ specific deficiencies, our providers improved in many key steps and especially in timely initiation of uninterrupted chest compressions, the single most important step in successful resuscitation. Initiation of chest compressions by an obstetric provider during maternal code has to occur within seconds of recognition of cardiac arrest, when an experienced resuscitation team may not have had a chance to arrive. Yet, shocked by an unanticipated, rare event, obstetric providers sometimes may not start or delay initiation of CPR while awaiting the arrival of help. We show that a simulation-based intervention allows the providers to be more confident and to initiate appropriate steps in a more timely fashion. We demonstrated statistically significant improvement in critical care performance scores, largely due to marked improvement in timely initiation of uninterrupted chest compressions, as

well as recognition of a cardiac rhythm requiring defibrillation and use of the defibrillator. Providers did not show improvement in completing tasks on our checklist related to initial airway management and appropriate use of medications performance. This is reflected in a postintervention median score of 7 of maximum 16 on the critical care portion of the performance checklist. However, in a real life scenario, the single most important step for an obstetric provider encountering maternal code is initiation of timely uninterrupted appropriately performed chest compressions until an experienced resuscitation team arrives to take over the airway management and medication administration. Therefore, our intervention demonstrates success with the potential to impact maternal and fetal outcomes. Repeated interval simulation may lead to further improvement in performance of initial airway management and medication administration during maternal cardiac arrest among the obstetric providers, however, these portions may not be crucial for the obstetric team to master. During maternal cardiac arrest, MFM providers improved the most in application of pregnancy-related modifications. Although many MFM providers demonstrated baseline knowledge of left lateral displacement, midsternal hand positioning, small endotracheal tube size use, continuous cricoid pressure use, and intravenous access use above the uterus, they failed to perform many of these steps during initial management and showed significant improvement after


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SMFM Papers the intervention. Although all the MFM providers knew to initiate cesarean delivery within 4 minutes of maternal cardiac arrest as indicated by their baseline knowledge test, this was actually not performed in a timely fashion during the initial simulation exercise. For example, some of the providers had asked to move the patient from the labor and delivery to the operating room, a decision that would not only delay the initiation of the cesarean delivery but also significantly diminish the quality of chest compressions during the move. After an intervention, all providers improved in timely initiation of cesarean delivery at the patient’s bedside. Our study supports prior data that simulation practice of emergencies helps translate provider knowledge into performance.7,12 Although level of experience did not affect the preintervention scores, we found that postintervention the providers with more years of practice performed significantly better. We also noted that those who had participated in actual cardiac arrest in the past performed better postintervention. This finding suggests that those with more experience benefit more from our intervention. Our intervention may have been enough for refreshing the memories and building on previous experience, but may have not been enough for those who are less experienced. Our program was heavily simulation based: after a preintervention simulation, each learner participated in a 1-on-1 debriefing session, which focused on individual deficiencies and stressed key learning concepts of cardiac arrest management. Our intervention consisted of a basic life support (BLS) course, which was followed by a simulation-based workshop, in which key ACLS maternal code learning objectives were reviewed and learners practiced cardiac arrest management in a simulated environment. We did not have a cohort without BLS training; however, prior studies have demonstrated that traditional training alone is not an optimal method to assure high quality CPR during an actual code.15,16 We believe that simulation training in addition to 239.e4

www.AJOG.org traditional methods allows for practice and sustainability of a skill. A limitation of our study is that we demonstrate a significant improvement during repeat simulated maternal cardiac arrest simulation and not during a real clinical event. Because of the rare nature of maternal cardiac arrest, we believe it to be extremely difficult to design a study demonstrating an impact of a simulation-based training program for the management of this condition. Anecdotally, a few weeks after our simulation intervention, an MFM fellow encountered an unresponsive pulseless patient on the postpartum floor and successfully, with confidence, managed the situation until arrival of the “code team.” In internal medicine, Wayne et al7 has demonstrated that residents trained using a simulator provided a higher quality care during actual resuscitation events compared with traditionally trained residents. Although ACLS training is typically required in medical specialties like internal medicine, it is not in obstetrics and gynecology or in MFM training. The combination of inadequate training and rare exposure to maternal cardiac arrest leaves obstetric providers and their patients at a grave disadvantage when they are faced with unexpected cardiac arrest on labor and delivery and postpartum floors. Although in other medical fields, traditional BLS/ACLS training methods alone have been shown to be insufficient, a complete absence of this basic training in obstetrics is concerning. We believe that the addition of a CPR and pregnancyfocused ACLS training requirement for all obstetric providers and especially MFM physicians would be a first step toward improving maternal cardiac arrest outcomes. We also believe that simulation-based practice, in addition to traditional training, will aid in achieving the goal of superior quality performance during the management of a maternal cardiac arrest. We have shown that a simulation-based workshop that included BLS training and focused on pregnancy-related modifications and critical care tasks in ACLS is beneficial to MFM providers in improving their performance and increasing their

American Journal of Obstetrics & Gynecology SEPTEMBER 2011

confidence and we believe this will translate into improvement management during the rare but critical occurrence of an f actual maternal cardiac arrest. REFERENCES 1. Lewis G, ed. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003-2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London, UK: CEMACH; 2007. 2. Datner E, Promes S. Resuscitation in pregnancy. In: Tintinalli’s emergency medicine. New York: The McGraw-Hill Co.; 2006:254. 3. Department of Health, Welsh Office, Scottish Office Department of Health, Department of Health and Social Services, Northern Ireland. Why mothers die: report on confidential enquiries into maternal deaths in the United Kingdom 20002002. London, UK: The Stationery Office; 2004. 4. Dijkman A, Huisman CM, Smit M, et al. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG 2010;117:282-7. 5. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122(Suppl 3):S640-56. 6. Seethala RR, Esposito EC, Abella BS. Approaches to improving cardiac arrest resuscitation performance. Curr Opin Crit Care 2010;16: 196-202. 7. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulationbased education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest 2008;133:56-61. 8. Lipman SS, Daniels KI, Carvalho B, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol 2010;203:179.e1-5. 9. American Heart Association. Part 10.8: cardiac arrest associated with pregnancy. Circulation 2005;112:150-3. 10. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12.3: cardiac arrest associated with pregnancy: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010:122 (Suppl 3):S833-7. 11. American Heart Association. Part 7.2: Management of cardiac arrest. Circulation 2005; 112:658-61. 12. Kory PD, Eisen LA, Adachi M, Ribaudo VA, Rosenthal ME, Mayo PH. Initial airway management skills of senior residents: simulation training compared with traditional training. Chest 2007;132:1927-31.

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