European Journal of Obstetrics & Gynecology and Reproductive Biology
Full length articleCost-effectiveness of simulation-based team training in obstetric emergencies (TOSTI study)
Introduction
Ensuring the safety of patients is an important aspect in emergency health care [1]. Even with modern obstetric practise the risk of a baby dying on the day of its birth in the UK is greater than the average daily risk of death until the 92nd year of life. Expressed as micromorts (number of one in a million chances of dying) the risk is comparable with undergoing major surgery. The lifetime risk of death in childbirth is low, but is concentrated in a short period, making being born a high-risk activity [2]. Giving birth is by all means a natural process, but the transition from a routine to an emergency situation can occur rapidly and unexpectedly. This gives obstetrical care workers the challenge to make high stakes decisions under major time pressure. In this process, medical errors can occur that sometimes have disastrous effects on patients [3], [4]. A considerable proportion of these medical errors are related to a lack of non-technical skills, including communication and teamwork skills [5]. Education of these non-technical skills might therefore improve patient safety. Despite the acknowledged importance of simulation-based team training in obstetrics, evidence from randomised controlled trials that team training improves maternal and perinatal outcome is still lacking [4], [5], [6].
In view of this identified knowledge gap, we performed a cluster randomised trial to assess the effectiveness of a one-day technology-enhanced obstetric team training in a simulation centre on patient outcome, during a one year follow-up (TOSTI study) [7], [8], [9]. Our trial revealed that a composite of obstetric complications was not reduced but analysis of the individual components of this composite outcome showed a significant two-fold reduction in neonatal damage due to shoulder dystocia (OR 0.50; 95% CI; 0.25–0.99) and a two-fold increase of treatment with ≥4 packed cells of blood transfusion, embolisation or hysterectomy in case of a postpartum haemorrhage (OR 2.2, 95% CI; 1.2–3.9).
In October 2012 the report ‘Ten years of maternity claims. An analysis of National Health Service litigation authority data' was released and described an analysis of the various clinical situations that have led to maternity claims. This report expressed hope that the information provided would be helpful to those professionals responsible for ensuring the provision of safe care for women and their babies [10]. Ten years of maternity claims consisting of 5087 maternity claims with a total value of £3.1 billion were analysed. A number of key points of learning emerged: effective multi-disciplinary team working and mutual professional respect is essential to the provision of safe care and there is a need for more effective training and development of staff. Dedicated programs which are flexible enough to enable attendance at training sessions or completion of online learning are needed.
Financial costs are also an important additional aspect of the assessment of an intervention and the subsequent decision to use it. Obstetric team training is often associated with considerable monetary and time costs but could also lead to cost savings by preventing obstetric complications. Zendejas et al. performed a systematic search on costs of simulation-based medical education (SBME) [11]. From a pool of 10,903 articles they identified 967 comparative studies. Their main conclusion was that cost reporting in SBME research is infrequent and incomplete. This emphasises the importance of cost-effectiveness studies in simulation-based training.
Here, we evaluate the cost-effectiveness of obstetric multi-professional team training in a medical simulation centre and of ‘on-site’ repetition training. These on-site sessions are described as a team based simulation strategy that occurs on the actual patient care units involving actual healthcare team members within their own working environment. Data were retrieved from the TOSTI study and for the composite outcome of obstetric complications and specifically neonatal trauma due to shoulder dystocia we calculated the incremental cost-effectiveness ratios (ICERs), which represent the costs to prevent the adverse outcome.
Section snippets
Trial design
We performed an economic analysis based on a randomised trial evaluating simulation-based team training in obstetric emergencies, the TOSTI trial. Full details of the TOSTI trial have been reported previously [8], [9]. 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
Resource use and costs
For the cost analysis we used data of 28,657 women with a singleton pregnancy delivering beyond 24 weeks of gestation in 24 participating hospitals. Of these 24 hospitals, 12 had been randomised for team training in the simulation centre and 12 for no such team training. Each study group contained five teaching and seven non-teaching hospitals. The starting time of the follow-up period of one year was synchronised with the moment that the entire hospital was trained.
Direct and indirect costs to
Principle findings
This study assessed the economic consequences of simulation-based team training in a medical simulation centre or no such training from a hospital point of view. We found that the mean costs per hospital generated by team training in a medical simulation centre to train all its personnel were €25,546 as compared to no such team training. The repetition courses, organised as half-day training sessions on-site, were €9035 per hospital. Dominant strategies were those including repetition training
Conclusion
Multi-professional team training in a medical simulation centre is cost-effective in a scenario where repetition training sessions are performed on-site.
Funding
This study is funded by ZonMw, the Netherlands Organisation 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.
Acknowledgements
We would like to thank neonatologist dr. P. Andriessen at the Máxima Medical Centre, for his support in estimating the costs for neonatal trauma due to shoulder dystocia.
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
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