Reducing errors in health care: cost-effectiveness of multidisciplinary team training in obstetric emergencies (TOSTI study); a randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>There are many avoidable deaths in hospitals because the care team is not well attuned. Training in emergency situations is generally followed on an individual basis. In practice, however, hospital patients are treated by a team composed of various disciplines. To prevent communication errors, it is important to focus the training on the team as a whole, rather than on the individual. Team training appears to be important in contributing toward preventing these errors. Obstetrics lends itself to multidisciplinary team training. It is a field in which nurses, midwives, obstetricians and paediatricians work together and where decisions must be made and actions must be carried out under extreme time pressure.</p> <p>It is attractive to belief that multidisciplinary team training will reduce the number of errors in obstetrics. The other side of the medal is that many hospitals are buying expensive patient simulators without proper evaluation of the training method. In the Netherlands many hospitals have 1,000 or less annual deliveries. In our small country it might therefore be more cost-effective to train obstetric teams in medical simulation centres with well trained personnel, high fidelity patient simulators, and well defined training programmes.</p> <p>Methods/design</p> <p>The aim of the present study is to evaluate the cost-effectiveness of multidisciplinary team training in a medical simulation centre in the Netherlands to reduce the number of medical errors in obstetric emergency situations. We plan a multicentre randomised study with the centre as unit of analysis. Obstetric departments will be randomly assigned to receive multidisciplinary team training in a medical simulation centre or to a control arm without any team training.</p> <p>The composite measure of poor perinatal and maternal outcome in the non training group was thought to be 15%, on the basis of data obtained from the National Dutch Perinatal Registry and the guidelines of the Dutch Society of Obstetrics and Gynaecology (NVOG). We anticipated that multidisciplinary team training would reduce this risk to 5%. A sample size of 24 centres with a cluster size of each at least 200 deliveries, each 12 centres per group, was needed for 80% power and a 5% type 1 error probability (two-sided). We assumed an Intraclass Correlation Coefficient (ICC) value of maximum 0.08.</p> <p>The analysis will be performed according to the intention-to-treat principle and stratified for teaching or non-teaching hospitals.</p> <p>Primary outcome is the number of obstetric complications throughout the first year period after the intervention. If multidisciplinary team training appears to be effective a cost-effective analysis will be performed.</p> <p>Discussion</p> <p>If multidisciplinary team training appears to be cost-effective, this training should be implemented in extra training for gynaecologists.</p> <p>Trial Registration</p> <p>The protocol is registered in the clinical trial register number NTR1859</p

External cephalic version: a safe procedure?:a systematic review of version-related risks

\u3cp\u3eBackground. The Term Breech Trial has considerably increased the number of cesareans. External cephalic version (ECV) might be an effective method of lowering the rate of cesareans; its efficacy has been well established. However, although in the absence of anesthesia the risks are thought to be low, most studies have used populations too small to allow definite conclusions on version-related risks. Methods. In an attempt to make an inventory of these risks, we have systematically analyzed 44 studies, covering a total of 7377 patients from 1990 to 2002. The studies used were derived from a Medline and Embase search. Results. The most frequently reported complications were transient abnormal cardiotocography (CTG) patterns (5.7%). Persisting pathological CTG readings (0.37%) and vaginal bleeding occur rarely (0.47%). The incidence of placental abruption was even lower, at 0.12%. Fetomaternal transfusion was absent in five out of seven studies, with a mean incidence of 3.7%. Emergency cesareans were performed in 0.43% of all versions. Perinatal mortality was 0.16%. Conclusions. External cephalic version seems to be a safe procedure.\u3c/p\u3

Development of the prop chart, a new visual model to evaluate the effectiveness of training with computerised manikins

\u3cp\u3eHigh-fidelity manikins and new computerised simulation methods play a key role in medical training. Despite the on-going developments in computer technologies and widespread use of computerised simulation methods, the most effective use of these technologies in medical training is still ambiguous. To give insight into the effectiveness of medical simulation training of health care professionals and to design more effective trainings, we created the Prop chart. This chart is initially developed for the training of multi professional teams using medical simulation. A literature search for evidence based features of effective medical simulation was combined with the opinion of experts in focus group discussions. Ten features of medical simulation that contribute to effective learning were identified and were used in the Prop chart. The experts agreed on the convenience of the Prop chart to evaluate and design medical simulation training programs. Future research will focus on the applicability of the Prop chart for fields outside the medical world and other new training methods like serious gaming.\u3c/p\u3

Een interactief foetusmodel voor de simulatie van stuitbevallingen

Geen samenvatting

Tocogram characteristics of uterine rupture:a systematic review

\u3cp\u3ePurpose: Timely diagnosing a uterine rupture is challenging. Based on the pathophysiology of complete uterine wall separation, changes in uterine activity are expected. The primary objective is to identify tocogram characteristics associated with uterine rupture during trial of labor after cesarean section. The secondary objective is to compare the external tocodynamometer with intrauterine pressure catheters. Methods: MEDLINE, EMBASE, and the Cochrane library were systematically searched for eligible records. Moreover, clinical guidelines were screened. Studies analyzing tocogram characteristics of uterine rupture during trial of labor after cesarean section were appraised and included by two independent reviewers. Due to heterogeneity, a meta-analysis was only feasible for uterine hyperstimulation. Results: Thirteen studies were included. Three tocogram characteristics were associated with uterine rupture. (1) Hyperstimulation was more frequently observed compared with controls during the delivery (38 versus 21 % and 58 versus 53 %), and in the last 2 h prior to birth (19 versus 4 %). Results of meta-analysis: OR 1.68 (95 % CI 0.97–2.89), p = 0.06. (2) Decrease of uterine activity was observed in 14–40 % and (3) an increasing baseline in 10–20 %. Five studies documented no changes in uterine activity or Montevideo units. A direct comparison between external tocodynamometer and intrauterine pressure catheters was not feasible. Conclusions: Uterine rupture can be preceded or accompanied by several types of changes in uterine contractility, including hyperstimulation, reduced number of contractions, and increased or reduced baseline of the uterine tonus. While no typical pattern has been repeatedly reported, close follow-up of uterine contractility is advised and hyperstimulation should be prevented.\u3c/p\u3

Arterial balloon occlusion of the internal iliac arteries for treatment of life-threatening massive postpartum haemorrhage:a series of 15 consecutive cases

\u3cp\u3eObjective: To evaluate arterial balloon occlusion of the internal iliac arteries for treatment of life-threatening massive postpartum haemorrhage. Study design: Retrospective cohort study at a tertiary referral perinatal centre in a teaching hospital in the Netherlands. All patients who delivered in our hospital between January 1998 and January 2008 were included in the study. A retrospective analysis of all cases of postpartum haemorrhage was performed. All 15 consecutive cases of massive postpartum haemorrhage were selected from an electronic database. The patients with massive postpartum haemorrhage (blood loss &gt; 5000 ml) and the patients with postpartum haemorrhage treated with arterial balloon occlusion of internal iliac arteries were analyzed. Results: In the study period 1246 (7%) of all 17,308 deliveries were complicated by postpartum haemorrhage. 15 (0.1%) patients suffered from massive postpartum haemorrhage. They were all treated with balloon occlusion of the internal iliac arteries. Hysterectomy was performed in 4 patients. All patients survived without any complications. Conclusion: Arterial balloon occlusion of the internal iliac arteries is a safe and in most cases effective procedure for treatment of massive life-threatening postpartum haemorrhage.\u3c/p\u3

Inter- and intra-observer variation of fetal volume measurements with three-dimensional ultrasound in the first trimester of pregnancy

\u3cp\u3eObjectives: To determine the inter- and intra-observer variation of volume calculations of human fetuses at a gestational age of 11 \u3csup\u3e+0\u3c/sup\u3e-13 \u3csup\u3e+6\u3c/sup\u3e weeks by three-dimensional ultrasound (3DUS). Methods: 3DUS datasets were acquired during nuchal translucency measurements. The fetal volume (FV) was measured in 65 cases by two independent investigators. The Virtual Organ Computer aided AnaLysis (VOCAL™) imaging software was used to manually calculate the FV (rotational angle 9°). Inter- and intra-observer variation were assessed by Bland-Altman plots and intraclass correlation coefficients (ICC). Results: Both inter- and intraobserver reproducibility were highly reliable as shown by the Bland-Altman plots and an ICC of respectively 0.934 and 0.994. Conclusion: FV calculation by 3DUS with VOCAL and a rotational angle of 9° is feasible and has a high inter- and intraobserver reliability in the first trimester of pregnancy.\u3c/p\u3

Normal fetal cardiac deformation values in pregnancy:a prospective cohort study protocol

\u3cp\u3eBackground: Myocardial deformation imaging offers the potential to measure myocardial function. Remodelling, the change in size, shape and function, appears as a result of pressure or volume changes and is thought to be the first sign of fetal adaptation to placental dysfunction. Deformation can be measured using speckle tracking echocardiography (STE). STE in the fetus might be useful for detection and follow up of the fetus endangered by placental dysfunction. Reference values for fetal myocardial deformation during gestation have not been comprehensively described and need further investigation before STE can be introduced in daily clinical practice. The aim of this study is to determine reference values for fetal myocardial deformation throughout gestation in uncomplicated pregnancies. Methods: A longitudinal cohort will be performed. 150 Women, pregnant from a non-anomalous singleton, will be included from 19 to 21 + 6 weeks gestational age. Thereafter, fetal heart ultrasounds will be performed 4 weekly, until 41 weeks gestational age or delivery. Ultrasound data will be analysed using STE software to determine reference values for fetal cardiac deformation during gestation. Discussion: Measuring cardiac deformation changes in pregnancy can be a promising tool to detect preclinical cardiac adaptation to placental dysfunction. However, previous studies used different ultrasound scans and STE software resulting in incomparable and contradictory results on deformation values. In this prospective study reference values during pregnancy, cardiac deformation values will be assessed with the same ultrasound and software package in 150 uncomplicated pregnancies.\u3c/p\u3

Fetal monitoring

\u3cp\u3eA system for monitoring a fetus during gestation comprises an input for receiving a plurality of electric signals measured on a surface of a maternal body; and means for providing a fetal electrocardiogram based on the received electric signals and based on an orientation of the fetus, wherein the fetal electrocardiogram represents a projection of a fetal cardiac potential vector according to a predetermined projection direction that is fixed with respect to the fetus. The fetal vector electrocardiogram is projected according to the projection direction. An at least partial representation of a fetal vector electrocardiogram is provided in dependence on the plurality of electric signals and indicative of a time path of an electrical field vector generated by a fetal heart of the fetus.\u3c/p\u3