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Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial

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Abstract

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. J van de Ven, AF Fransen, E Schuit, PJ van Runnard Heimel, BW Mol, SG Oei

Objective

To investigate whether the effect of a one-day simulation-based obstetric team training on patient outcome changes over time.

Study design

Post-hoc analysis of a multicentre, open, randomised controlled trial that evaluated team training in obstetrics (TOSTI study).We studied women with a singleton pregnancy beyond 24 weeks of gestation in 24 obstetric units. Included obstetric units were randomised to either a one-day, multi-professional simulation-based team training focusing on crew resource management in a medical simulation centre (12 units) or to no team training (12 units). We assessed whether outcomes differed between both groups in each of the first four quarters following the team training and compared the effect of team training over quarters. Primary outcome was a composite outcome of low Apgar score, severe postpartum haemorrhage, trauma due to shoulder dystocia, eclampsia and hypoxic-ischemic encephalopathy.

Results

During a one year period after the team training the rate of obstetric complications, both on the composite level and the individual component level, did not differ between any of the quarters. For trauma due to shoulder dystocia team training led to a significant decrease in the first quarter (0.06% versus 0.26%, OR 0.19, 95% CI 0.03 to 0.98) but in the subsequent quarters no significant reductions were observed. Similar results were found for invasive treatment for severe postpartum haemorrhage where a significant increase was only seen in the first quarter (0.4% versus 0.03%, OR 19, 95% CI 2.5–147), and not thereafter.

Conclusion

The beneficial effect of a one-day, simulation-based, multiprofessional, obstetric team training seems to decline after three months. If team training is further evaluated or implemented, repetitive training sessions every three months seem therefore recommended.

Introduction

Ensuring the safety of patients is an important aspect in emergency health care, including obstetrics [1]. Patient safety in obstetric care has an extra dimension because the health of both mother and child are at risk [2]. Unexpected life-threatening events can happen at every moment, challenging obstetric care teams to make decisions under major time pressure. Consequently, medical errors occur which can have extensive effects for patients [3], and [4]. A considerable proportion of these medical errors are related to a lack of non-technical skills, such as communication and teamwork [5]. Training of these non-technical skills is therefore thought to be important to improve patient safety. In fact, a recent review showed that the use of simulation training is effective for educating communication and critical thinking skills [6]. Our research group showed that technology-enhanced simulation team training in obstetrics, with a special focus on non-technical skills, was associated with a better team performance on the Clinical Teamwork Scale [7] and significant better use of technical skills [8]. Similar results were found in other studies [9], and [10] but randomised controlled trials are scarce and only moderate benefits were identified on patient outcome [11], and [12]. In view of the identified knowledge gap, we conducted a cluster randomised trial to assess the effectiveness of a one-day simulation-based obstetric teamwork training in a simulation centre on the number of obstetric complications, during a one year follow-up (TOSTI study) [13], and [14]. The primary outcome, which was a composite of neonatal and maternal obstetric complications was comparable in the intervention and control group. A breakdown of the primary outcome indicated less trauma due to shoulder dystocia in the intervention group and increased invasive treatment for severe postpartum haemorrhage.

One of the possible limitations of this one-day intervention was that a decay of trainees' acquired skills may have occurred during the one year follow-up after training, resulting in a decline of the effect of simulation-based team training on patient outcome. To assess this decay we performed a post-hoc analysis of the TOSTI trial and divided the one year follow-up in four equal periods of three months assuming that most effects on patient outcomes will be seen in the first period after team training in comparison with the later periods.

Section snippets

Trial design, study population and intervention

We performed a post-hoc analysis of a cluster randomised clinical trial that evaluated the effect of simulation-based team training on patient outcome, the TOSTI trial. Full details of the TOSTI trial, including the CONSORT flowchart, were reported previously [8], [13], and [14]. In short, the study was a multicentre cluster randomised controlled trial performed between November 2009 and July 2011 to evaluate the effectiveness of a simulation-based obstetric teamwork training in a medical

Results

There were 24 units randomised and included in the analysis (see CONSORT flow chart in Fig. 1). Each study group contained five teaching and seven non-teaching units. The starting time of the follow-up period of one year was synchronised with the moment that the entire unit was trained. In total, 74 multi-professional teams received the training, consisting of 74 gynaecologists, 36 residents, 79 midwives and 282 nurses. Participation rates of the healthcare profesionals of the included

Comment

Our multicentre, cluster randomised controlled trial revealed that a one-day, multi-professional, simulation-based obstetric team training in a simulation centre, focusing on teamwork skills, did not reduce a composite of obstetric complications. This was also the case in this post-hoc analysis. A breakdown of the components of the primary outcome showed a reduction in the number of trauma due to shoulder dystocia in the intervention group. Our current study shows that this effect was mainly a

Conflicts of interest

The authors declare that they have no competing interests.

Funding

This study is funded by ZonMW, the Netherlands Organization for Health Research and Development, grant (170992303). This organisation was not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Ethical approval

As this was a cluster randomised clinical trial allocating interventions at a group level, the institutional review board of the Máxima Medical Centre in Veldhoven, the Netherlands judged that ethical approval was not necessary. The trial has been registered in the Dutch trial register number NTR 1859.

Acknowledgements

Participating hospitals

We thank all 24 hospitals for participating in our study. Per Dutch cluster:

Cluster Amsterdam: Kennemer Gasthuis Haarlem, Rode Kruis Hospital Beverwijk, Waterland Hospital Purmerend. Cluster Brabant: Catharina Hospital Eindhoven, Sint Anna Hospital Geldrop, Sint Elisabeth Hospital Tilburg, Sint Jans Gasthuis Weert, Tweesteden Hospital Tilburg. Cluster Groningen: Scheper Hospital Emmen. Cluster Leiden: Diaconessenhuis Leiden, Groene Hart Hospital Gouda, Langeland Hospital

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