ILLINOIS DEPARTMENT OF PUBLIC HEALTH · Web view2016/01/01 · To quantify blood loss, have individuals weigh all of the items and calculate blood loss and record on answer sheet

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

January 1, 2016

[ILLINOIS DEPARTMENT OF PUBLIC HEALTH]

Illinois Department of Public Health

Obstetric Hemorrhage Education Project

Instructor Resource Manual

FOREWARD

Medicine is a constantly changing science, and new research findings necessitate continual changes in drug and treatment therapies. The developers of this project have made reasonable efforts to provide up-to-date, accurate information that is within generally accepted medical standards at the time of this publication.

August, 2015

2015 Committee Members

Felicia Fitzgerald, BSN, RNC-OB, C-EFM, Obstetric Outreach Educator, University of Chicago

Lori Folken, BSN, RNC-OB, C-EFM, Perinatal Outreach Educator, Carle Foundation Hospital

*Paula Melone, DO. FACOG, Assistant Professor, Loyola University Health System

Angela Rodriguez, RNC-OB, BSN, CCRC, Perinatal Coordinator, Advocate Illinois Masonic

*Shirley Scott, MS, RN-BC, C-EFM, APN, University of Illinois at Chicago

Original Obstetric Hemorrhage Education Project (OHEP) Workgroup, July 2008

OHEP Workgroup:

Linda Blakley, RNC, BSN, South Central Illinois Perinatal Network

Laurie Deihs, RN, MPH, MS, University of Chicago Perinatal Network

*Robin Jones, MD, Chair of MMRC, Rush University Medical Center

*Andrea Kemp, MD Member of MMRC, Mac Neal Hospital

*Kevin Madsen, MD, Member MMRC, Good Samaritan Hospital

*Trish O’Malley, RNC, MS, WHNP, ANP, Loyola University Perinatal Network

*Patricia Prentice, RN, MBA, Rush Perinatal Network

Pamela Randazzo, RNC, BSN, St. Louis University Perinatal Center

Shirley Scott, RNC, MS, APN, University of Illinois Perinatal Network

*Louise Simonson, RNC, MS, WHNP, University of Illinois Perinatal Network

*Members of the Maternal Mortality Review Committee

Obstetric Hemorrhage Education Project

Instructor Resource Manual

Program Goals and Objectives

Course Description: This course focuses on the application of current management options to prevent, diagnose, manage and treat hemorrhage during pregnancy and the postpartum period.

Course Goals:

To improve:

(1) Risk assessment and preparation for possible hemorrhage

(2) Quantification of blood loss (EBL)

(3) Recognition and treatment of hemorrhage/hypovolemia

To review:

(1) How to initiate the obstetric and/or hospital wide Rapid Response team

(2) How to initiate the hospital’s rapid transfusion protocol

(3) The protocol for quantification of blood loss

(4) The protocol for active management of the third stage of labor

Outcomes of Project: Reduction of maternal morbidity and mortality from obstetric hemorrhage in Illinois

IDPH Responsibilities: The Illinois Department of Public Health, through the work of the Obstetric Hemorrhage Education Project (OHEP) Workgroup, has developed a comprehensive program which includes:

· Development of Program/Project Components

· Benchmark Assessment Validation

· Didactic presentation

· Required resource articles

· Skill stations

· Simulation drill

· Post-program Benchmark Assessment Validation

Hospital Responsibilities:

All hospitals providing maternity services in Illinois will be required to continue to participate in the IDPH Hemorrhage Education Project. All newly employed staff, including regular and agency personnel, must complete the project, including simulations, within one year of service. Existing hospital staff that has completed the project previously, must be updated with new recommendation and hospital protocols within one year of the programs release.

Each hospital with maternity services is required to submit course completion dates to their perinatal center yearly. This information will also be a part of the hospitals site visit review.

In addition, based on individual hospital resources, each hospital providing maternity services in Illinois will:

· Continue to identify internal strengths and challenges in recognizing and managing patients experiencing obstetric hemorrhage

· Require all new members of the Obstetric Care Provider team(see page 6) to demonstrate completion of all components of the Obstetric Hemorrhage Education Project. Nursing assistants and technicians must participate in the quantification of blood loss station and drill only. Unit secretaries must participate in the drill only.

· Continue to review patients who received > 4 units of blood products/ICU admission for appropriate care, which is part of their continuous quality improvement program and morbidity and mortality review meetings

· Continue to conduct simulated drills and debriefing of simulated and actual cases

· Update hemorrhage policies /guidelines

· Hospitals must provide documentation of new and existing staff completion of the program

Perinatal Center Responsibilities:

The project continues to be implemented as part of each Network’s Continuous Quality Improvement program.

Each of the 10 Administrative Perinatal Centers will:

1. Provide technical advice to the hospital “champions”

2. Initiate “train-the-trainer” classes for network hospitals as needed

3. Develop a method to monitor progress within their network

Program Components

The Resource Manual includes instruction for implementation of the Benchmark Assessment Validation, didactic lecture, skill stations and drill with debriefing.

COMPONENTS OF THE OBSTETRIC HEMORRHAGE EDUCATION PROJECT:

I. Benchmark Assessment Validation (30 minutes)

II. Didactic Lecture and Discussion (90 minutes)

III. Skill Stations (30 minutes)

IV. Simulation Drills (30 minutes each)

V. Debriefing (60 minutes)

This course is designed to be completed in a four hour time frame and each hospital may choose one of several alternatives for implementation. Examples of options are listed below:

Implementation Options

Option 1

Option 2

Option 3

Option 4

Complete in a single session, Benchmark Assessment Validation, didactic lecture, skill stations and simulation

1. Web based format for Benchmark Assessment Validation

2. Classroom for didactic lecture, discussion, skill station and drill

Complete in components, i.e.:

1. Benchmark Assessment Validation at staff/department meeting

2. Didactic lecture at Grand Rounds

3. Skills station and drill at the end of Grand Rounds or schedule at a later date

1. Web based format for Benchmark Assessment Validation

2. Videotape lecture and assign individuals to review or place on Learning management system

3. Skills station and drill at schedule at a later date

A minimum of one physician and one nurse “champion” at each hospital has been identified to implement the Obstetric Hemorrhage Education Project at their institution. Although this team will be ultimately responsible for the project as a whole, additional staff may be needed and used to help with various aspects/components of the program. For example, quantification of blood loss skill stations can be assigned to one or more staff members. Debriefing after a simulation can include a different team, and administration of the Benchmark Assessment Validation can be another team

PARTICIPANTS:

All new staff providing care for obstetric patients must demonstrate completion of all components of the Obstetric Hemorrhage Education Project

The Obstetric Care Provider team is defined as all:

· MD/DO/Midwives with delivery privileges

· Obstetric Registered Nurses

· Residents and/or Fellows

· Anesthesia providers (attendings, residents, CRNAs) who practice obstetrics

OB providers who practice at more than one institution will be required to complete the following components ONCE and provide proof of completion to all hospitals in which they provide services:

(1) Benchmark Assessment Validation

(2) Didactic lecture

(3) Skill stations

The following component must be completed at each hospital at which services are provided:

(1) Simulation drill

If an institution utilizes their existing hospitals medical-surgical Rapid Response Team (RRT), they will be required to send those team members to complete all components of the Obstetric Hemorrhage Education Project.

All members of the OB care team must participate in the blood estimation stations (including nursing assistants and technicians) and drill (including nursing assistants, technicians and clerical support).

Educational Philosophy

Circle of Learning to Help Build Competence

The Circle of Learning is a framework that identifies four modes of learning and illustrates an

ongoing process of achieving competence.

I.BENCHMARK ASSESSMENT VALIDATION (30 minutes)

Questionnaire (25 questions) *

Purpose

· To assess the individual participant’s baseline knowledge

· To customize the program to most effectively meet the needs of the participants

· To assess program efficacy based on pre-assessment versus post-assessment validation scores

Hospital Facilitators / Champions Responsibilities:

· From the test bank, select 25 test questions

· Administer the assessment in the most time-effective method that does not compromise the integrity of the assessment questions.

· Ensure participants take the benchmark validation assessment prior to participating

in the lecture, discussion, skill station and drill.

· Promote targeted teaching, review/clarify assessment outcome information during

the lecture and drill.

· Establish a system for scoring and recording assessment scores as well as tracking completion and reporting progress to the Perinatal Center.

*The same questionnaire that is used to assess the participant’s baseline knowledge prior to the education, should be repeated six months after the completion of the education.

II. DIDACTIC LECTURE and DISCUSSION (90 minutes)

The following steps are to be included for all implementation options

Purpose

To improve:

· Risk assessment and preparation for possible hemorrhage

· Quantification of blood loss

· Recognition and treatment of hemorrhage/hypovolemia

To discuss hospital policies and procedures on:


· Active management of the third stage of labor for vaginal deliveries

· Patients who desire not to accept blood products

· A Massive transfusion protocol


Videotaping Guidelines

If a facility plans to videotape the lecture to show to subsequent classes, please abide by the following:

· Release forms should be signed by all participants per hospital protocol

· The Benchmark Assessment Validation is given to all participants prior to videotaping so the lecture can be customized to address frequently missed questions.

· The videotape/digital video disc (DVD) should be continuous, unedited and placed on high quality media

· There should be breaks in the didactic lecture to allow for questions from the participants viewing the video/DVD

· Videos/DVDs can focus on a particular participant while he or she is talking, but should focus on the speaker and the class as much as possible

· Individuals who view the video/DVD and have questions need to be answered immediately after the video presentation

STEPS FOR IMPLEMENTATION

Step 1

Prior to implementation review the following articles: Copyright infringement laws prohibit inclusion of articles in manual.

· Abdil-Kadir, R., McLintock, C., Ducloy, A., El-Refaey, H., England, A., Federici, A., Peyvandi, F. &. W., R. (2014). Evaluation and management of postpartum hemorrhage: Consensus from an international expert panel. Transfusion, 54, 1756.

· American College Of Obstetrics and Gynecologists. (2014). Maternal safety bundle for obstetric hemorrhage. Retrieved from http://www.acog.org/-/media/Districts/District-II/PDFs/SMI/v2/he01F140602PowerPointPDFOct2014.pdf?la=en

· Dutton, R., Lee, L., Stephens, L., Posner, K., & Davies, J. & Domino, K. (2014). Massive hemorrhage: A report from the anesthesia closed claims project. Anesthesiology, 121(3), 450.

· Brock D, Abu-Rish, E., Chiu, C., Hammer, D., Wilson, S., Borvick, L., Blondon, K., Schaad, D., Liner, D., Zierier, B. (2013). Interprofessional education in team communication: working together to improve patient safety. Quality and Safety in Health Care, 22:414–423. doi:10.1136/bmjqs-2012-000952

· Lagrew, D. (2014). Postpartum hemorrhage: state and national response. Current Opinion in Hematology, 21(6), 528-533. doi 10.1097/MOH.0000000000000091

Step 2

1. Distribute and score the Benchmark Assessment Validation.

2. Offer and summarize Benchmark Assessment Validation and initiate group discussion to review answers with rationales.

Step 3

1. Using the PowerPoint© presentation developed by the OB Hemorrhage Education Project Workgroup, discuss key points of risk assessment, identification, diagnosis, treatment/interventions, communication and documentation

· Each slide has a script with key points to emphasize

2. Personalize information by incorporating hospital specific components into the didactic lecture:

· Incorporation of hemorrhage definition into current documentation

· Current Massive transfusion/Hemorrhage Policy

· Current Rapid Response Policy

· Current par/baseline levels and turnaround times for blood products (can be taken from the hospital assessment)

· Expected lab results times

· Discuss other available hospital resources (Example: Interventional Radiology, Surgical Subspecialists)


· Active management of the third stage of labor for vaginal deliveries

· Patients who desire not to accept blood products

Step 4

1. Six months after the completion of the complete program, the same Benchmark Assessment Validation is given to each participant and scored

NOTE: The participants should be strongly encouraged to supplement the education by reviewing the following articles prior to participation. Copyright infringement laws prohibit inclusion of articles in manual.

· Abdil-Kadir, R., McLintock, C., Ducloy, A., El-Refaey, H., England, A., Federici, A., Peyvandi, F. &. W., R. (2014). Evaluation and management of postpartum hemorrhage: Consensus from an international expert panel. Transfusion, 54, 1756.

· Brock D, Abu-Rish, E., Chiu, C., Hammer, D., Wilson, S., Borvick, L., Blondon, K., Schaad, D., Liner, D., Zierier, B. (2013). Interprofessional education in team communication: working together to improve patient safety. Quality and Safety in Health Care, 22:414–423. doi:10.1136/bmjqs-2012-000952

III. SKILL STATIONS (30 minutes)

Quantification of blood loss of various amounts

The skill station component can be included at the end of the didactic lecture or can be conducted separately.

NOTE: Examples of blood materials weights could become permanent displays in a break or classroom; when and where staff complete the skill station should be adapted to each specific hospital setting.

Purpose

1. To promote accurate quantification of blood loss by weighing clean and used hospital materials. For example:

· Peripads

· Disposable underpads

· Laparotomy sponges (18X18 in.)

· 4X4 gauze squares

2. Categorize the severity of blood loss

3. Advocate for the practice of weighing blood-soaked items as the most accurate assessment of blood loss

4. Review the dry weight of the most common hospital items (e.g. chux, peripads)

5. Review process for using graduated drapes for vaginal deliveries

6. Review how to measure blood loss during all deliveries

NOTE: All members of the OB care team (including nursing assistants and technicians) must participate in the quantification of blood loss station. If an institution utilizes their existing hospitals medical-surgical Rapid Response Team (RRT), they will be required to send those team members to complete all components of the Obstetric Hemorrhage Education Project.


STEPS FOR IMPLEMENTATION

Step 1


· Zukerwise, L., Pettker, C., Illuzzi, J., Raab, C., Lipkind, H. (2014). Use of novel visual aids to improve estimation of obstetric blood loos. Obstetrics & Gynecology, 123(5), 982-98. doi; 10.1097/AOG.0000000000000233

· Al Kadri, H. M. F., & Al Anazi, B.K. & Tamim, H. (2011). Visual estimation versus gravimetric measurement of postpartum blood loss: A prospective cohort study

Archives of Gynecology and Obstetrics, 282(6), 1207-1213.

· Association of Women's Health, Obstetrics, and Neonatal Nursing. (2014). Quantification of blood loss: AWHONN practice brief number 1. Journal of Obstetrics and Neonatal Nursing, (00), 1-3. doi:10.1111/1552-6909.12519

These articles demonstrate a variety of ways on how to conduct skills stations. For the purpose of this manual, the set up will be described using disposable underpads, peripads and laparotomy sponges.

Step 2

Prior to setting up the skill stations:

1. Make imitation blood and clots, recipes included at the end of this section and in hemorrhage supply kit.

2. Determine dry weights of all products used for blood absorption.

3. Weigh peripads and lap sponges for saturation volumes.

4. Make a product chart and post. (Example included at the end of this section).

5. Gather supplies. (See list below).

Skill Station # 1 - Quantification Blood Loss (<500ml)*

Items Needed:

· Peripads


· Index cards

· Syringes to draw up the exact amount of blood

· Imitation blood and clots (unless able to obtain outdated blood from your blood bank)

· Jell-O to make clots (see recipe below)

· Easter egg molds (optional)

· Imitation blood recipe

· Gloves

· Scale

Step 3

Skill Station Set-up

1. Gather supplies.

2. Set up a table with peripads and/or lap sponges, on disposable underpad and clots.

3. Randomly place imitation blood and blood clots on products in intervals of:

50ml, 100ml, 150ml, 200ml, 300ml, etc. Use different colored blood and blood clots to demonstrate fresh versus old blood. Number items 1-5

4. Weigh and record weights on an answer sheet for the facilitator

5. To quantify blood loss, have individuals weigh all of the items and calculate blood loss and record on answer sheet*.

6. Have individuals check their answer with the facilitator.

* This method gives individuals practice simple quantification of small amounts

Skill Station # 2 – Quantification of Blood Loss (>500ml)

Step 1

Items Needed:

· Peripads


· OR suction canisters

· Surgical sponge counting bags

· Laparotomy sponge

· Kidney basin

· Syringes to draw up exact amount of blood

· Imitation blood and clots (unless you are able to obtain outdated blood from your blood bank) Sizes and amounts can differ

· Jell-O to make clots; recipes included at the end of this section**

· Imitation blood recipe

· Gloves

· Scale

· QBL Calculator for Cesarean Section

Additional items that can be used:

· Graduated delivery drape (under buttocks)

· 4X4 sponges

Step 2

Skill Station Set-up

1. Pick items from the “Items Needed” list, (i.e., peripad, clots, suction canister, and laparotomy sponge).

2. Fill/soak various items with blood of various amounts.

3. To quantify blood loss, have individuals weigh all of the items and calculate blood loss and record on answer sheet

4. Have individuals determine if the “patient” needs a transfusion. If so, have individual determine what products should be used for replacement based on your massive transfusion protocol.

5. Record results on the answer sheet

Alternative

· Have the participants complete the QBL calculator from the California Quality Collaborative with the supplies above

** Water balloons are a good substitute for clots. Weigh the balloons after filling them with

various amounts of water. For a firmer clot, place in the freezer for a few hours.

***Decorative water crystal beads or “aqua beads” and aquarium sand can also be used to simulate clots

You can also purchase Eastland Water beads from Quick Candles in bulk http://www.quickdecor.com/catalogsearch/result/?cat=0&q=clear+water+pearls

Simulated blood can be purchased online from a variety of vendors. Key search words: Simulate blood powder or Trueclot

IMITATION BLOOD RECIPES

(CAREFUL, it will stain)

Blood Recipe #1 (new blood)

Makes ~ 500 ml Cost: ~ $4.80 / 500 ml

Ingredients

· 16 oz white corn syrup

· 1 oz red food coloring

· 1 oz dishwashing detergent (blue color is better)

· 1 oz water

· 1000 ml NS bottle from surgery to hold the product

1. Mix 16oz white corn syrup, 1oz red food coloring, 1oz dishwashing detergent

and 1oz water.

2. Do not shake or stir. Mixture will contain bubbles.

3. Make it look more authentic by adding 1- 2 drops of blue food coloring.

4. For mixing and storing, save 1000 ml NS bottles from surgery.

Blood Recipe #2 (old blood)

Makes ~ 200 ml

Ingredients

· 2/3 cup corn syrup

· 1/3 cup water

· 5 tablespoons cornstarch

· 3 to 5 teaspoons red food coloring

· 2 or 3 drops green food coloring

1. Mix the cornstarch thoroughly with the water.

2. Add the corn syrup and mix well.

3. Add red food coloring into the mixture, using only 3 teaspoons at first.

4. Add a couple drops of green food coloring to take the pink edge off the red food coloring.

If the mixture is too light, add one or two teaspoons more of red food coloring.

5. Add an extra drop of green food coloring if the mixture gets too pink again.

IMITATION CLOT RECIPES

Clot Recipe #1

· 4 packets of Knox Gelatin

· 1 box of Cherry Jell-O

· Red and blue food coloring

1. Mix Knox Blox recipe (found on the back of the box) with 1 box black cherry Jell-O.

2. Add the recommended amount of water instead of fruit juice.

3. Add red and/or blue food coloring to obtain the color you prefer.

4. If you do not have access to a scale, measure the liquid in a measuring cup

and put it into a resealable bag, or make in a container and scoop out and weigh before the course.

Clot Recipe #2

Make Jell-O according to Jell-O package. Make different sizes using a syringe to measure the volume of the clot. Place in refrigerator until firm.

Use a variety of Jell-O to represent old versus new blood:

· Black cherry and strawberry mixed for old clots

· Cherry or strawberry for new clots

Platelet Recipe

· 5 oz (2/3 cup) of water

· 1 tablespoon cornstarch

· 1 tablespoon cornmeal

· 1 teaspoon oatmeal

· 1 drop of yellow food coloring

Mix dry ingredients and water completely. The mixture should be loose, but add more water if necessary. Add a few drops of food coloring and mix. Place in a blood bag for use.

Dry Weight Product Chart

Product Name

Product Picture

Approximate dry weight (grams)

2 X 2 gause

20 grams

ABD dressing

30 grams

Large PeriPad

28 grams

Lap Sponge

15 grams

Light Peripad

12 grams

SKILL STATIONS BLOOD ESTIMATION ANSWER SHEET

(Place items on table and have participants fill in quantification amounts for items displayed)

NAME (PRINT)____________________________________________________________

Part 1

ITEM

(pad, sponge, etc)

WEIGHED AMOUNT (ML)

ACTUAL AMOUNT

1.

2.

3.

4.

5.

Part 2

ITEM

WEIGHED AMOUNT

Running Total

1.

2.

3.

4.

5.

6.

7.

8.

Grand Total

Should the patient be transfused? □ No □ Yes

Per hospital massive transfusion protocol, what products should be replaced?

How many units for each product checked?

□ PRBC _______units

□ FFP _______units

Cryoprecipitate _______units

□ PLTS _______pks

□ IV Fluid ______ L

Other ______________

IV. SIMULATION DRILLS

Simulation drills are made up of two parts: the drill and the debriefing. Simulation-based training involves immersion of the trainee in a realistic scenario created within a physical space (simulator) that replicates a realistic environment. A simulator is a physical space designed to replicate a real life work environment. It includes equipment, monitors and alarms that must be manually adjusted and acknowledged.

NOTE: All members of the OB care team (including nursing assistants, technicians, and clerical staff) must participate in the drill. If an institution utilizes their existing hospitals medical-surgical Rapid Response Team (RRT), they will be required to send those team members to complete all components of the Obstetric Hemorrhage Education Project.

Providers and staff (including nursing assistants, technicians and clerical support) who practice at more than one institution will be required to participate in simulation drills at each of the institutions in which privileges are granted.

Additional personnel may be required to implement a simulation drill.

Purpose

· To plan and implement collaborative practice obstetric hemorrhage mock drills.

· Facilitate interdisciplinary teamwork in an threating environment

· Identify potential needs for change and enhance communication and skill


Observe, record start and end times, and debrief participants on the mock drill

· Documents performance of the drill using the mock drill checklist (included at end of this section).

· Implement a debriefing session after each mock drill is completed

· Complete debriefing evaluation tool in each mock drill

Supplies for Simulation

Bed

IV start equipment

Blood drawing equipment

Lap sponges

Blood pressure machine and cuff

Mannequin (if appropriate)

Cardiac monitor and its supplies

Medications

Disposable underpads

Obstetrical Emergency Kit

Doppler

Obstetrical Surgical Kit

Fetal monitor and its supplies

Oxygen tank, tubing and mask

Foley catheter (straight and indwelling)

Peripads

Gram scale

Pulse oximeter

Imitation blood and clots

Stethoscopes

IV poles and pumps

Uterine packing material

IV solutions (non-dextrose)

STEPS TO IMPLEMENTATION

Step 1


· Rudolph, J., Simon, R., Dufresne, R., Raemer, D. (2006). There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 1(1), 49-55.

· Chang, E. (2013). The role of simulation training in obstetrics: a healthcare training strategy dedicated to performance improvement. Current Opinion in Obstetrics & Gynecology. 25(6):482-486. DOI:10.1097/GCO.0000000000000030

· Miller, K., Riley, W., Davis, S., Hansen, H. (2008). In situ simulation: a method of experiential learning to promote safety and team behavior. Journal of Perinatal and Neonatal Nursing, 22 (2), 105-113 doi 10.1097/01.JPN.0000319096.97790.f7.

· Seropian, M. (2003). General Concepts in Full Scale Simulation: Getting Started. Anesthesia Analog, 97, 1695-1705.

Step 2

Gather supplies for drill.

Suggestions to make the drill more realistic:

· Admit the “patient” to the hospital with a medical record number

· Make a patient chart which includes prenatal record, H&P, laboratory data, relevant consultative notes, FHR tracings since admission etc.

· Provide appropriate lab results

· Standing order sets (See example in sample forms folder).

· Develop hemorrhage flow sheet for ongoing patient assessment and management (See example in sample forms folder).

· Develop a hemorrhage “Code” alert system

· Develop roles for the professional and ancillary nursing staff

· Develop a unit based telephone directory

· Review existing surgical trays for adequacy of instruments

Step 3

Mock Drill Observation / Evaluation

Educate the participants about mock drills by discussing what elements of the performance will be evaluated:

· Technical skills

· Critical thinking skills

· Overall performance (individual and team)

Videotaping Guidelines

If a facility plans to videotape the lecture to show to subsequent classes, we suggest the following:

· Release forms should be signed by all participants per hospital protocol

· Inform participants that this video/DVD is confidential and will only be used during that debriefing session. If possible, destroy after use.

· The videotape/DVD should be continuous, unedited and placed on high quality media.

· Individual’s questions are answered during the debriefing session.

Step 4

Choose one of the sample mock drills, read introduction and present the case to participants

Step 5

Begin drill, record start and end times, and use the mock drill check lists to document actions

NOTE: “The Simulation Experience Presentation” is included for review prior to the drill.

Included at the end of this section:

Case 1 – Antepartum Placenta Previa (Simulated on DVD)

Case 2 - Rectus Muscle

Case 3 – Grandmultiparity

Case 4 – Uterine Rupture

The scenarios provided are intended to be customized based on the facility’s level of care, location, staffing patterns, hospital resources. Please use the hospital’s assessment form to individualize the approach to the simulation cases.

Each simulation/mock drill contains:

· Objectives

· Teaching points

· Performance check-list with key tasks that are to be performed by the team (highlighted in yellow)

The time frames provided are estimates and should be adapted to the simulation/clinical setting.

V.Debriefing

Debriefing is the process where participants are guided through a purposeful discussion of an experience. The goals of debriefing are:

· Explore each participant’s perceptions of his/her experience

· Assess participant learning

· Determine if learning objectives and teaching points have been met

Preparing for the debriefing of a simulation drill requires as much care and attention as preparing for the drill. The facilitator’s role is to:

· Maximize participation from all members

· Encourage individuals to reflect on their experience and articulate their perspective

· Encourage the group to explore, gain insight and learn from the experience

When doing a simulation, the debriefing should occur immediately following the experience. If a facility has an actual hemorrhage case, debriefing should occur within seventy-two (72) hours and can be used in place of a simulation. At all times, a facilitator is required to guide the debriefing process (real patient situation or simulation drill).


STEPS TO IMPLEMENTATION

Step 1

Mock Drill Evaluation

Evaluation includes:

· Technical skills

· Critical thinking skills

· Overall performance (individual and team)

Step 2

Debriefing

· Promote discussion from the participants.

· Evaluate behavior, critical thinking and communication skills identified

How to Facilitate the Debriefing:

· Set expectations for the participants

· Guide the session to achieve case scenario objectives

· Facilitate discussion on teaching points

· Engage “quiet” participants

· Ensure that all critical topics are discussed

· Reinforce positive aspects of team performance

What to Avoid in a Debriefing:

· A rigid agenda

· Instructor-centered session

· Instructor analysis and evaluation before participants’ analysis and evaluation

Debriefing Suggestions

Facilitator’s Techniques for Debriefing

· Use open ended questions to elicit team participation

· Guide team to topics to enhance discussion

· Use silence as a strategy and tactic

· Use active listening (e.g., non-verbal, echoing, reflecting and expanding) for effective evaluation

· Use videos to evaluate team performance (if applicable)

· Discuss how new knowledge is related to participant’s knowledge

Suggested Statements for Opening Comments

State, “Everyone may have a different focus during a hemorrhage, we need all of you to”:

· Contribute ideas

· Listening to and learning from each other

State, “We are going to have the unique opportunity to reflect on a common experience. Usually, people have an experience, but then go their separate ways without formally reflecting on it.”

Questions to Facilitate a Debriefing Session

· “What were your greatest frustrations and/or successes?”

· “What was your principal challenge?”

· “What did you think you were doing?”

· “How much collaboration between nurses and physicians occurred in making the decisions for the patient?”

· “How satisfied were you with the decision made for the patient?”

· “Would you say open communication between physicians and nurse took place as decisions were made for the patient?”

· “In making decisions, were nursing and medical concerns about the patient addressed?”

· “Does one always need to ……..?”

· “What are the risks and benefits of ……?”

· “How do you assure you have what you need for…?”

Suggestions to Address Emotional Responses

The Facilitator should:

· Give some quiet time for people to explore their feelings

· If nobody volunteers to speak, make an authentic affective statement (“Tell me what went well?”)

· Suggest they use “I feel….

· Listen attentively to the content and feeling of any statement

· Listen empathetically by reflecting on the speaker’s emotions

· Ask for clarification of statements you do not understand, without appearing to trap the speaker

· Keep calm

· Don’t become defensive

· Thank the speaker for sharing their feelings

Suggestions for Video Feedback

· “What was going on in your mind when…… was occurring?”

· “Does everyone agree how that happened, let’s play back the video?”

· “What was going through your mind during this section?”

· “This was a critical situation! What was……?”

The Participant’s Commandments of Simulation Based Training

1. Know your environment

2. Anticipate and plan for crises

3. Assume a leadership role

4. Communicate effectively

5. Distribute workload optimally

6. Allocate attention wisely

7. Utilize all available resources

8. Utilize all available information

9. Call for help early

VI. Evaluation

Evaluation is collecting information about a program or some aspect of a program in order to make necessary adjustments to the program.

Why Evaluations are Useful:

· Improves efficiency of delivery

· Validates current practice

· Indicates and validates whether the goals are being met

· Measures the effectiveness of the program for duplication elsewhere

Some basic ideas for an evaluation have been provided, but please feel free to add additional questions that are specific to the facility.

We highly encourage each facility to obtain CME/CEU hours for this program.

Skill Proficiency

To develop psychomotor skills through repetitive practice during simulation drills

Knowledge Acquisition

Process of acquiring knowledge through resources, such as research articles, national standards

Team Simulation

Group practice of realistic scenarios to improve teamwork, leadership and communication to produce a standardized experience

Clinical Experience

Learning through reflecting on the treatment of real life experiences and exchange of knowledge with colleagues

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Obstetric Hemorrhage Education Project Instructor Resource Manual

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