Train the trainer

1. Global Outreach Mobile
Obstetric Medical
Simulation (GO MOMS)
India “Train the Trainer” 2020

2. Goal of the
day
• To help you learn how to run simulations in
your hospitals
• We will include:
• Lectures
• Watch a simulation
• Perform a variety of simulations yourself

3. Overview
Setting the tone for simulation training
Creating the simulation scenario
Team training principles
Debriefing techniques
Using simulation to uncover system errors
Wrapping up/take away

4. Simulation compared to traditional medical
education
Traditional medical
training conveys the
knowledge needed
to care for patients
Simulation allows
teams to practice
what they have
learned

5. How simulation is used to optimize your team or :
How to make a team of experts into an expert team
• Communication
techniques
• Closed loop
• Recaps
• Delegation of roles
• Leadership

6. Basic
assumption:
We start with the basic
assumption that :
Everyone participating in this
simulation training is intelligent,
well-trained, cares about doing
their best and wants to improve
patient safety

7. Setting the tone:
Create a safe
environment for
training
Creating a Safe Zone
https://www.lenmallen.com/

8. Next steps
Skills station
• Review tasks
Scenario
• Apply knowledge and skills in a realistic
setting
• Learn best ways to work as a team
• Communication
Delegation of roles and tasks
• Using a checklist

9. Creating
scenarios
Use
Use an actual patient case for the scenario if
possible
Determine Select 2-3 learning objectives to focus on

10. Learning
objectives
Identification of the reason for
the postpartum hemorrhage
Treatment for a postpartum
hemorrhage from uterine atony
• Medications - correct dosage
• Uterine balloon tamponade - correct
placement
• Efficiently obtaining blood for
transfusion

11. Learning
objectives
Other possible learning
objectives
• Understanding information that
needs to be given to anesthesia
or pediatrics when they enter the
room
• Using simulation to help the
nurses determine how to
delegate roles in a crisis
• Efficiently obtaining medications

12. Day of
Simulation:
Briefing
• Introductions - everyone (including team
members) should introduce themselves
• Statement "We start with the basic
assumption that everyone participating in
this simulation training is intelligent, well-
trained, cares about doing their best and
wants to improve patient safety."
• Explanation of the need for a safe zone
• Signing of the confidentiality form
• Describe the day’s events:
• Familiarization with the sim room and
equipment
• Skills training (if you are including that
before the simulation)
• Simulation
• Debriefing

13. Using a checklist in an emergency

15. Using simulation to introduce use of a checklist
A checklist is not a ‘how to
manual’
A checklist is a ‘to do list’
§Jogs memory
§Reduces failure
§Ensures consistency
§Ensures completeness

16. Use of
checklist for
training:
• Review information on the checklist
• Familiarize staff with checklist
• Decide who will be the ‘reader’ or
team member responsible for using
the checklist
• Decide the best way to use a checklist
on your unit
1. During simulation/actual patient
event: to guide practice, or
2. After the event to assure
everything has been done

17. Checklist
Example
PPH Checklist
Recognize Call for Help Treat
Transfuse
early
STEP 2: IDENTIFY & TREAT CAUSE ~ Atony, Laceration, Retained Placenta, Coagulopathy
□ Vitals q1-2 min □ PPH kit + PPH cart
□ 100% oxygen □ Fundal massage
□ IV fluids - high rate □ Urinary catheter
□ 2 wide-bore IVs □ Uterotonics
Pitocin 1-2 u IV bolus (anesthesiologists only)
Max 30 u/500 mL (max rate 500 mL/hr)
Always inform an anesthesiologist if administering
2nd
-line uterotonics:
Methergine 0.2 mg IM q2-4 hr __________
Hemabate 0.25 mg IM q15 min __________
Repeat dose @ __________
Misoprostol 600-800 mcg SL __________
STEP 3: ASSESS MAGNITUDE
Phase 1 (first 5 - 10 min)
□ Consider doing a RECAP now
□ Send STAT labs (ABG, CBC, PT/PTT, INR, Fibrinogen, iCa, TEG)
□ Activate MTG □ Resuscitate using Belmont
□ Assess QBL □ Bakri balloon
Phase 2 (10 - 15 min)
□ Early transfer to OR (if bleeding is ongoing) or IR (if bleeding ongoing + stable)
□ Consider fibrinogen concentrate (RiaSTAP), or cryoprecipitate
□ Consider tranexamic acid 1 g IV
□ Treat hypocalcemia □ Maintain normothermia
STEP 1: CALL FOR HELP!
□ OB Rapid Response (211) □ Primary OB□ OB Chief Resident (650 444-9844)
□ OB Anesthesia (Attending: 650 721-0865 Fellow: 650 7210866 Resident:650 7210867)
□ Assign nursing roles
Time given:

18. Example
Scenario:
Patient history
SIMULATION TEAM TELLS LEARNERS THE
FOLLOWING
Your patient is Maria Gonzalez
28 yo g4p3 @ 40 weeks gestation who
presented at 7 cm dilation with SROM and
clear fluid 1 hour ago
Pmhx: healthy, no allergies, no medications
Pt rapidly advanced to complete and pushed
for 25 minutes with delivery of a baby girl
(3800 gram)
Placenta remains in the uterus 30 minutes
after delivery

19. SCENARIO
BEGINS:
Simulation team then says,
“I have to go – can you please deliver the
placenta?”
LEARNERS BEGIN SIMULATION
VS: HR 98, BP 100/60, Resp 28, Temp 37C
Exam: Umbilical cord extending out of the
vagina, small amount of bleeding
MD participant is asked to deliver the
placenta
RN participate is asked to assume the role
of the nurse

20. Scenario: PPH
The placenta is delivered easily but
then the patient begins to bleed
profusely
EBL/VS:
1000cc, HR 100, BP 95/50
1500 cc, HR 130, BP 90/50
2500 cc, HR 140, BP 70/40

21. Endpoints
1. Bleeding will continue unless 2
uterotonic medications have been
administered
2. UBT is placed
3. VS will only improve after a blood
transfusion is started

22. Debriefing
Overview
Definition: A discussion among those being
trained that covers learning objectives, questions
that the trainees may have, and events that
occurred during the simulation
Role of the debriefer:
• Facilitate discussion by asking questions of
trainees, debriefer does not lecture but helps
the team discuss issues and questions that
result from the simulation
• Ensure all trainees participate in the discussion
including the perspective of all disciplines in
the scenario

23. Debriefing Pearls: Key points of good debriefing
• Framing the discussion – getting the debrief started
• “We will be using the checklist as a guide in our
debriefing.”
• Characteristics of good debriefing
• Open questions asked to the entire team
• Avoid
• Grilling questions
• Don’t you know….
• GUESS what I am thinking?
• Asking multiple questions at once

24. Debriefing
Questions
Utilizing a
Checklist
•
STEP 1: CALL FOR HELP!
□ Primary OB □ OB Chief Resident
□ Anesthesia
□ Assign roles
1. What do doctors want to know when they are
called urgently to provide help?
2. How can the team be sure to include this
information when calling for help?
3. Does someone assign roles to the team, if so who
and how do they do it?
4. How does having a role affect patient care?

25. Debriefing
Questions
Utilizing a
Checklist
STEP 2: IDENTIFY & TREAT CAUSE ~ Atony,
Laceration, Retained Placenta, Coagulopathy
□ Vitals q1-2 min □ PPH kit + PPH cart
□ 100% oxygen □ Fundal massage
□ IV fluids - high rate □ Urinary catheter
□ 2 wide-bore IVs □ Uterotonics
1. Were all the steps done to decide on the correct
diagnosis?
2. What medications were needed for this patient?
3. What circumstances facilitated the woman getting
the medications she needed?
4. What circumstances delayed/prevented the woman
from getting the medications she needed?
Pitocin Max 30 u/500 mL (max rate 500 mL/hr)
Methergine 0.2 mg IM q2-4 hr _________
Carboprost 250 mg IM _________
Misoprostol 600-800 mcg SL __________

26. Debriefing
Questions
Utilizing a
Checklist
STEP 3: ASSESS MAGNITUDE and treatment
Phase 1 (first 5 - 10 min)
□ Consider doing a RECAP now (review what has been done and plan next
steps)
□ Send labs (ABG, CBC, PT/PTT, INR, Fibrinogen)
□ Obtain blood (transfuse 1-2 PRBC/1 FFP)
□ Assess EBL □ UBT/Bakri balloon for atony
1. Was a recap done?
2. Was everyone aware of what was happening?
3. Did the team face any challenges or barriers
placing the uterine tamponade device?
4. Did the team face any barriers or challenges
obtaining blood products?
5. What can be done to obtain blood efficiently on
the unit/ward?

27. Debrief issues: Communication
• Closed loop/Check back communication technique
Sender Receiver
Close looped
Check back

28. Communication
Recap
• A technique to be sure that everyone in the
room/OR are on the same page at the same
time

29. Debriefing
issues:
Delegation of
roles
• Who assigns roles in your unit
during an emergency?
• What works well with the
present system and what are
the challenges?

30. Debriefing issues: Leadership
• Who leads and why?
• What happens if the
“leader” is occupied

31. Debriefing
Questions:
Teamwork
Communication:
• Was closed loop communication used?
• What needs to be communicated about
patient status and the plan of care?
Leadership:
• Who was the leader?
• How did having a leader or not having a
leader impact patient care?
• What can be done on the unit to make sure
a leader is identified?

32. Simulation and the Hospital System
• We can look at the hospital system to determine:
• Why the team was unable to accomplish what the patient
needed?
• What can be changed to overcome this challenge?
• Organization of equipment
• Availability of supplies
• Identify challenges obtaining crucial items
• Information then is brought to administration
• System errors are corrected

33. Take Away
Lessons learned:
“What did you
learn today that
you will use at
work
tomorrow?”

34. Summary
Step by Step:
Pre planning
1. Create learning objectives
2. Create simulation scenario
3. Determine number of learner
4. Assign role to simulation team
members
5. Develop an equipment list of
what you will need
6. Determine a schedule for the
day

35. Step by Step:
Day of
simulation
1. Introductions - everyone (including team members)
should introduce themselves
2. Statement "We start with the basic assumption that
everyone participating in this simulation training is
intelligent, well-trained, cares about doing their best and
wants to improve patient safety."
3. Explanation of the need for a safe zone
4. Events of the day
• Familiarizing learners with the sim room and
equipment
• Didactic or task training (if you are including that before
the simulation)
• Simulation
• Debriefing
• Discuss if there are any system errors on the unit that
need correcting
• Take home messages shared with the group

36. Simulation can be used to improve
safety on the unit üImproves team
performance
üCorrects
obstacles on the
unit
Improves patient
care!!!