Obstetric emergencies: training with skills drills

Chapter 24 Obstetric emergencies: training with skills drills



Andrew Simm



CHAPTER CONTANTS


Guidelines 214

Training in acute obstetric emergencies 214
Formats 214
National courses 214

Local courses 214

Debriefing after incidents or real emergencies 214

Fire drill 214

Efficacy of training 215

Example of fire drill for major obstetric haemorrhage 215
Planning 215

Running the scenario 216

Feedback 217

Learning from the drill 217
Team working and communication 217

Contacting emergency teams 217

Equipment 217

Local clinical governance, reinforced by various national structures, now underpins the functioning of the National Health Service (NHS). It requires the establishment of systems and ways of working that result in an improved standard of care for patients (Chief Medical Officer 2000).


Within obstetrics it is recognised that many untoward outcomes are unpredictable and unpreventable, but many reports have highlighted substandard care as being contributory to adverse outcomes (Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) (1999), Chief Medical Officer (2000) Confidential Enquiry into Maternal and Child Health (CEMACH) (2004)).


As a result litigation costs are high, as often is the human cost. Rarely is one factor alone responsible, and investigation of such incidents has now moved from a culture of blame to one of analysing systems that have contributed to the event, and seeking to establish measures that will help prevent a recurrence (Chief Medical Officer 2000).


• Adverse outcomes are now systematically investigated at a local level (as part of a risk management strategy) and national level, the latter most notably portrayed by CEMACH (2004).

• The Clinical Negligence Scheme for Trusts (CNST) (2005) requires evidence of strategies in place to identify and minimise risk, and so hopefully reduce litigation.

• Both CEMACH and CNST highlight the need for establishing guidelines for the management of various clinical conditions, and rehearsing these in the form of a ‘fire drill’. The Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives endorse this.

This is driven by the notion that although many complications of childbirth are infrequently encountered, they have a propensity to be catastrophic. Prompt appropriate management endeavours to reduce serious morbidity and mortality.



GUIDELINES



• Guidelines are established to provide an evidence base for management of specific conditions. Evidence is graded according to its quality and applicability (RCOG 2000). Where good evidence is lacking, expert opinion is utilised.

• They are produced at a national level, most notably by the RCOG and the National Institute of Health and Clinical Excellence (NICE).

• They are usually adapted by individual institutions in the recognition that they must be workable within the organisation of that hospital.

• The danger in guidelines is that they are adopted as policy that must not be breached. By their nature they are there to ‘guide’, and must be individualised to suit the needs of each patient.

Nonetheless, the usefulness of guidelines cannot be understated. They provide an easy source of reference for those on the ‘shop floor’ where uncertainty regarding management exists. They also provide some uniformity to management.


Some regions have adopted regional guidelines for conditions such as severe pre-eclampsia, thus facilitating audit of management of a condition infrequently encountered within individual institutions. This also allows familiarisation and uniformity for junior medical staff rotating within a region, when previously individual units adopted different guidelines.



TRAINING IN ACUTE OBSTETRIC EMERGENCIES



Formats



National courses


The two most established courses in the UK are:


• Advanced Life Support in Obstetrics (ALSO) course

• Managing Obstetric Emergencies and Trauma (MOET) course.

These combine lectures and skills practice to train candidates in a wide variety of clinical scenarios relevant to obstetric practice. Experienced instructors give standardised teaching. A uniform way to tackling a given scenario is provided. Feedback from participants regarding the courses is very positive.



Local courses


These usually take the form of scenario-based classroom teaching. Many have been based on the national courses described.



Debriefing after incidents or real emergencies



Fire drills


These have been cited by CEMACH and CNST and are discussed further below.



Fire drill


Various names have been given to these, e.g. skills drill, emergency drill, and fire drill. The term is imprecisely defined, and takes numerous formats. A survey of practice in 2003 assessed what format of drill individual units were undertaking, and how these drills were being organised and evaluated. The authors proposed the term ‘fire drill’ should imply the drill is conducted in the normal working environment (most commonly the labour ward) without prior knowledge of the staff involved (Anderson et al 2005). This has the following advantages:


• testing local systems and guidelines for given clinical scenarios

• testing multidisciplinary teamwork among professionals who usually work together in the same unit, as well as individual skills and knowledge.

A ‘fire drill’ has additional benefits to training from that undertaken in the classroom or at a site distant from one’s usual workplace and work colleagues.


At the time of the survey half of the responding units were conducting ‘fire drills’ as defined above. Many units were undertaking other forms of training in obstetric emergencies in addition to or in place of fire drills.


The positive aspects of fire drills as reported in the survey are:


• Increased confidence in emergency teamwork.

• Better multidisciplinary working.

• Improved physical organisation e.g. of emergency equipment.

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Mar 16, 2017 | Posted by in NURSING | Comments Off on Obstetric emergencies: training with skills drills

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