Safety Through Simulation

In the Department of Obstetrics & Gynecology, we use simulation to improve proficiency and outcomes in both basic skills and the unexpected emergency.

Our quality and safety program includes simulation exercises so care teams are prepared to provide the best care even during rare emergencies.

Simulation is gaining increasing recognition as a valuable teaching technique as residency program hours are shortened. It also strongly reinforces standard teaching techniques for students, residents and staff through hands-on learning. Professional organizations such as American College of Obstetricians and Gynecologists (ACOG) are becoming more cognizant of the need to demonstrate surgical skill certification and maintenance of such. The simulation room at Massachusetts General Hospital is an exciting opportunity for the Department of Obstetrics & Gynecology to create programs that are uniquely suited to our fields and needs.

Obstetrical Training

The CAE Lucina is a wireless, state-of-the-art obstetrical model with monitoring of both baby and maternal vital signs that can be programmed to simulate routine or complicated clinical scenarios. Our residents and staff can practice complicated situations such as shoulder dystocia, operative vaginal and breech delivery.

Since Lucina is a wireless free-standing model, she can be transferred to MGH Learning Lab, the Edwards Simulated Operating Room, or our labor and delivery floor for use in multidisciplinary obstetric emergency exercises. By using both the MGH Learning lab and our own delivery unit as locations for simulation care, we are able to replicate clinical scenarios that maximize patient safety, and allow direct observation of the team’s mobilization of personnel and resources on the labor unit. Over the years, our safety drills team has developed emergency exercises in maternal crisis management. Our scenarios range from a massive post-partum hemorrhage to anesthesia complications. Over the past decade, our team has coordinated over 50 simulated scenarios and provided education for over 100 providers every year.

During these exercises, communication, mutual respect, cross monitoring and the importance of the specific roles of each member of the team are emphasized. These drills have reinforced the close professional relationships between the obstetricians, midwives, and anesthesia and nursing teams on the labor unit. The broad staff involvement has clearly demonstrated the commitment to patient safety.

Outpatient Emergency

Our safety drills team is working with the Yawkey outpatient clinics to develop a rapid response team scenario. This multidisciplinary simulation will involve all doctors, nurses and medical assistants reinforcing the emergency medical response protocol for a patient emergency occurring in the outpatient setting.

Laparoscopy Training

Laparoscopy, often known as minimally invasive surgery or “band-aid surgery,” is a surgical technique performed through small incisions in the abdomen. Laparoscopic simulation is used as part of a new provider’s training and to maintain compliance of those already trained including:

• FLS Program and Training – Basic skills in suturing, cutting and knot tying
• Virtual Reality – Laparoscope model simulates more complicated procedures and monitors individual progress through competencies

Other Gynecologic Modules and Curriculum

Further simulation teaching is rotated on an annual basis, providing opportunity to assess our residents in:

• Hysteroscopy simulation
• Tension-free vaginal tape (TVT) sling model
• Fourth degree episiotomy repair model
• Office gynecology, including IUD and endometrial biopsy
• Contained tissue extraction for large fibroids

Mass General Fertility Center

At the Mass General Fertility Center, an emergency situation is unlikely, but we want to be prepared. Approximately once a year, our IVF procedure suite becomes the site of a “mock emergency” where we work with our physicians, nurses, medical assistants, administrative staff and embryologists to recreate an urgent problem. We involve the Anesthesia Department as well as Mass General Police and Security.

Our simulated cases have involved a respiratory arrest in a “patient” recovering from anesthesia, and another “patient” with life-threatening bleeding after an egg retrieval. Each scenario is followed by a team debriefing where we discuss the team’s response to the situation, from the moment the emergency is identified until the patient is safe and stable.

How Simulation Exercises Help to Improve Care

A potentially serious complication of labor is shoulder dystocia. A shoulder dystocia can occur when a baby gets stuck behind the mother’s pelvic bone while traveling through the birth canal. If the baby is not delivered quickly, there can be serious complications for the newborn baby and mother.

Despite being uncommon and difficult to predict, shoulder dystocia scenarios require an obstetrical team that can quickly identify the complication and rapidly formulate and institute a plan of care. One of the best ways of preparing for such potential events is through practical simulation training.

Our shoulder dystocia simulation project aims to improve the care we provide by recreating the scenario in a realistic location with actual care teams. Our doctors, nurses and midwives work together in small groups using sophisticated birthing simulators to improve our communication, teamwork and medical management during an emergency. Each simulation is followed by an open and detailed discussion to help all of our providers learn from each other.

Through simulation exercises, the obstetrical care teams at Mass General are prepared to handle rare emergency situations and provide better care for the families we care for on the Labor and Delivery Unit.