BACKGROUND: Although simulation is now widely used to improve teamwork and communication, there is limited data demonstrating improvement in clinical outcomes. OBJECTIVE: Our aim was to examine the clinical performance and outcomes associated with postpartum hemorrhage due to uterine atony following implementation of a multidisciplinary simulation program. STUDY DESIGN: This was a prospective observational study of response to postpartum hemorrhage due to uterine atony in an academic medical center before (Epoch 1: July 2017-June 2018) and after (Epoch 2: July 2019-June 2020) implementing multidisciplinary simulation. Twenty-two postpartum hemorrhage simulations were performed from July 2018-June 2019 involving more than 300 nursing, obstetric, and anesthesia providers. Simulation focused on management of a postpartum hemorrhage event as well as improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of simulation, the primary outcome was response to postpartum hemorrhage defined as time from uterotonic to first unit of blood administration in the first twelve hours following delivery comparing Epoch 2 to Epoch 1 following deployment of simulation. Statistical analysis included use of the Pearson chi-square, Wilcoxon rank sum, Hodges-Lehmann statistic for differences, and bootstrap methods with P<0.05 considered significant. RESULTS: Between July 1, 2017 and June 30, 2018 there were 12,305 patients who delivered, of which 495 patients, or 4% (495/12,305), required transfusion. Between July 1, 2019 and June 30, 2020 there were 12,414 patients who delivered, of which 480 patients, or 4% (480/12,414), required transfusion. When isolating cases of postpartum hemorrhage due to uterine atony in both transfused groups, there were 157 women before (Epoch 1) and 165 women after (Epoch 2) simulation, respectively. There was no difference in age, race, parity or perinatal outcomes between the two epochs. Women in Epoch 2 began receiving blood products significantly earlier in the first twelve hours following delivery compared to Epoch 1 (51 [28,125] min versus 102 [32,320] min, P=0.005). There was also significantly decreased variation in time from uterotonic to blood administration in Epoch 2 (P=0.035). Women in Epoch 2 also had significantly lower EBL when compared to Epoch 1 (1250 [1000,1750] mL versus 1500 [1000,2000] mL, P=0.032). CONCLUSIONS: Implementation of a multidisciplinary simulation program at a large academic center targeting management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from uterotonic administration to transfusion, decreased variance in time from uterotonic to blood administration and lower estimated blood loss following deployment of simulation. Because delay in treatment is a major cause of preventable maternal death in obstetric hemorrhage, these Results provide clinical evidence that simulation may improve patient outcomes in this emergency.
BACKGROUND: Although simulation is now widely used to improve teamwork and communication, there is limited data demonstrating improvement in clinical outcomes. OBJECTIVE: Our aim was to examine the clinical performance and outcomes associated with postpartum hemorrhage due to uterine atony following implementation of a multidisciplinary simulation program. STUDY DESIGN: This was a prospective observational study of response to postpartum hemorrhage due to uterine atony in an academic medical center before (Epoch 1: July 2017-June 2018) and after (Epoch 2: July 2019-June 2020) implementing multidisciplinary simulation. Twenty-two postpartum hemorrhage simulations were performed from July 2018-June 2019 involving more than 300 nursing, obstetric, and anesthesia providers. Simulation focused on management of a postpartum hemorrhage event as well as improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of simulation, the primary outcome was response to postpartum hemorrhage defined as time from uterotonic to first unit of blood administration in the first twelve hours following delivery comparing Epoch 2 to Epoch 1 following deployment of simulation. Statistical analysis included use of the Pearson chi-square, Wilcoxon rank sum, Hodges-Lehmann statistic for differences, and bootstrap methods with P<0.05 considered significant. RESULTS: Between July 1, 2017 and June 30, 2018 there were 12,305 patients who delivered, of which 495 patients, or 4% (495/12,305), required transfusion. Between July 1, 2019 and June 30, 2020 there were 12,414 patients who delivered, of which 480 patients, or 4% (480/12,414), required transfusion. When isolating cases of postpartum hemorrhage due to uterine atony in both transfused groups, there were 157 women before (Epoch 1) and 165 women after (Epoch 2) simulation, respectively. There was no difference in age, race, parity or perinatal outcomes between the two epochs. Women in Epoch 2 began receiving blood products significantly earlier in the first twelve hours following delivery compared to Epoch 1 (51 [28,125] min versus 102 [32,320] min, P=0.005). There was also significantly decreased variation in time from uterotonic to blood administration in Epoch 2 (P=0.035). Women in Epoch 2 also had significantly lower EBL when compared to Epoch 1 (1250 [1000,1750] mL versus 1500 [1000,2000] mL, P=0.032). CONCLUSIONS: Implementation of a multidisciplinary simulation program at a large academic center targeting management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from uterotonic administration to transfusion, decreased variance in time from uterotonic to blood administration and lower estimated blood loss following deployment of simulation. Because delay in treatment is a major cause of preventable maternal death in obstetric hemorrhage, these Results provide clinical evidence that simulation may improve patient outcomes in this emergency.