Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
Am J Obstet Gynecol. 2021 Oct;225(4):435.e1-435.e8. doi: 10.1016/j.ajog.2021.05.025. Epub 2021 May 28.
Although simulation is now widely used to improve teamwork and communication, data demonstrating improvement in clinical outcomes are limited.
This study aimed to examine the clinical performance and outcomes associated with postpartum hemorrhage because of uterine atony following the implementation of a multidisciplinary simulation program.
This was a prospective observational study of response to postpartum hemorrhage because of uterine atony in an academic medical center before (epoch 1: July 2017-June 2018) and after (epoch 2: July 2019-June 2020) implementing a multidisciplinary simulation program. A total of 22 postpartum hemorrhage simulations were performed from July 2018 to June 2019 involving more than 300 nursing, obstetrical, and anesthesia providers. The simulation program focused on managing postpartum hemorrhage events and improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of the simulation program, the primary outcome was response to postpartum hemorrhage defined as the time from the administration of uterotonic medications to transfusion of the first unit of blood in the first 12 hours following delivery, comparing epoch 2 to epoch 1 following the implementation of a simulation program. Statistical analysis included the use of the Pearson chi-square test, Wilcoxon rank-sum test, Hodges-Lehmann statistic for differences, and bootstrap methods with a P value of <.05 considered significant.
Between July 1, 2017, and June 30, 2018, there were 12,305 patients who delivered, of which 495 patients (4%) required transfusion. Between July 1, 2019, and June 30, 2020, there were 12,414 patients who delivered, of which 480 patients (4%) required transfusion. When isolating cases of postpartum hemorrhage because of uterine atony in both transfused groups, there were 157 women in the presimulation group (epoch 1) and 165 women in the postsimulation group (epoch 2), respectively. There was no difference in age, race, parity, or perinatal outcomes between the 2 epochs. Women in epoch 2 began receiving blood products significantly earlier in the first 12 hours following delivery compared with women in epoch 1 (51 [range, 28-125] minutes vs 102 [range, 32-320] minutes; P=.005). In addition, there was a significantly decreased variation in the time from the administration of uterotonic medications to transfusion of blood in epoch 2 (P=.035). Furthermore, women in epoch 2 had significantly lower estimated blood loss than women in epoch 1 (1250 [range, 1000-1750] mL vs 1500 [range, 1000-2000] mL; P=.032).
The implementation of a multidisciplinary simulation program at a large academic center focusing on the management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from the administration of uterotonic medications to transfusion of blood, decreased variance in the time from the administration of uterotonic medications to transfusion of blood, and lower estimated blood loss following the implementation of a simulation program. Because delay in treatment is a major cause of preventable maternal death in obstetrical hemorrhage, the results in our study provided clinical evidence that a simulation program may improve patient outcomes in such emergencies.
尽管模拟已广泛用于改善团队合作和沟通，但有关改善临床结局的数据有限。
本研究旨在检查与产后出血相关的临床表现和结局，原因是在实施多学科模拟项目后出现子宫收缩乏力。
这是一项在学术医疗中心对产后出血（由于子宫收缩乏力）的临床表现和结局进行前瞻性观察研究，该中心在实施多学科模拟项目之前（第 1 时期：2017 年 7 月至 2018 年 6 月）和之后（第 2 时期：2019 年 7 月至 2020 年 6 月）进行了研究。在 2018 年 7 月至 2019 年 6 月期间，共进行了 22 次产后出血模拟，涉及 300 多名护理、产科和麻醉提供者。模拟项目侧重于管理产后出血事件，并改善多学科团队的团队合作和沟通。为了评估模拟项目的临床效果，主要结局是产后出血的反应，定义为从使用宫缩药物到分娩后 12 小时内输注第一单位血液的时间，比较实施模拟项目前后第 2 时期与第 1 时期的情况。统计分析包括使用 Pearson 卡方检验、Wilcoxon 秩和检验、Hodges-Lehmann 统计差异和 bootstrap 方法，P 值<.05 被认为具有统计学意义。
在 2017 年 7 月 1 日至 2018 年 6 月 30 日期间，有 12305 名患者分娩，其中 495 名（4%）需要输血。在 2019 年 7 月 1 日至 2020 年 6 月 30 日期间，有 12414 名患者分娩，其中 480 名（4%）需要输血。在两个输血组中，孤立产后出血（由于子宫收缩乏力）的病例，模拟前组（第 1 时期）有 157 名女性，模拟后组（第 2 时期）有 165 名女性。两个时期的年龄、种族、产次和围产期结局无差异。与第 1 时期相比，第 2 时期的女性在分娩后 12 小时内开始接受血液制品的时间明显更早（51 [范围，28-125] 分钟与 102 [范围，32-320] 分钟；P=.005）。此外，在第 2 时期，从使用宫缩药物到输血的时间变化明显减少（P=.035）。此外，与第 1 时期相比，第 2 时期的女性估计出血量明显较少（1250 [范围，1000-1750] 毫升与 1500 [范围，1000-2000] 毫升；P=.032）。
在大型学术中心实施专注于产后出血管理的多学科模拟项目与改善临床反应相关。具体来说，从使用宫缩药物到输血的时间明显更快，从使用宫缩药物到输血的时间变化明显减少，模拟项目实施后估计出血量明显减少。由于治疗延迟是产科出血中可预防的产妇死亡的主要原因，因此我们的研究结果提供了临床证据，表明模拟项目可能改善此类紧急情况下的患者结局。
