key: cord-0829309-meyo7d02 authors: Mahoney, Bryan; Luebbert, Elizabeth title: Updates on Simulation in Obstetrical Anesthesiology Through the COVID-19 Pandemic date: 2021-11-11 journal: Anesthesiol Clin DOI: 10.1016/j.anclin.2021.08.001 sha: c9109b139498f912e65b35aa21fe0083c7573336 doc_id: 829309 cord_uid: meyo7d02 Simulation has played a critical role in medicine for decades as a pedagogical and assessment tool. The labor and delivery unit provides an ideal setting for the use of simulation technology. Prior reviews of this topic have focused on simulation for individual and team training and assessment. The COVID-19 pandemic has provided an opportunity for educators and leaders in obstetric anesthesiology to rapidly train health care providers and develop new protocols for patient care with simulation. This review surveys new developments in simulation for obstetric anesthesiology with an emphasis on simulation use during the COVID-19 pandemic. Simulation has played a critical role in medicine for decades as a pedagogical or assessment tool utilized at the levels of the individual, multidisciplinary team, and institution. The labor and delivery unit provides an ideal setting for leveraging the advantages provided by simulation given the variety of technical and clinical skills required by health care providers, the collaborative nature of patient care, the potential for unanticipated patient emergencies, and the consistent emphasis on quality improvement in patient care. A useful conceptual model for a survey of simulation in the field of obstetric anesthesiology discriminates the domains of training and assessment along an expanding continuum of learner cohorts: the individual, the patient care team, and the health care organization or environment. Prior reviews of this topic consistently have utilized this approach in surveying the literature on this topic. [1] [2] [3] [4] [5] [6] Given rapid advances in simulation technology and education, an update of simulation in obstetric anesthesiology is in order every few years. Simulation as a tool for training and assessment, however, has proved its utility during the COVID-19 pandemic as training programs and health care systems have been forced to navigate a radically altered learning and patient care environment requiring novel approaches to training and team-based care. This review continues in the tradition of surveying the newest literature on simulation training and assessment for individuals, teams, and systems while also providing a specific overview of the role of simulation in obstetric anesthesiology in the context of the COVID-19 pandemic and the shift toward the virtual learning environment accelerated by social distancing requirements during the pandemic. The practice of obstetric anesthesiology requires the acquisition of both technical skills and complex nontechnical clinical skills that extend beyond those to which anesthesiology trainees are exposed in the general practice of anesthesiology. Simulation technology can serve as a strategy for this skill acquisition. Partial task trainers (used to address a specific psychomotor or technical skill) and high-fidelity mannequinbased or virtual reality-based simulation (used to address clinical scenarios requiring complex multidomain skill acquisition) are both well described in the obstetric anesthesia simulation literature. A variety of partial task trainers for spinal or epidural neuraxial technique training have been described and made available to educators. These have ranged from a simulator constructed from a balloon, intubation pillow, and slice of bread, 7 to anatomically accurate manikin-based or computer-driven or haptic feedback-driven models allowing for trainee practice. 8 A 2013 review comparing 17 manikin-based simulators to 14 computer-based models by Vaughan and colleagues 8 notes that although manikin-based simulators are inexpensive, portable, and maintain a higher fidelity as a physical simulation of patient anatomy, computer-based models utilizing haptics provide real-time 3-dimensional screen-based visual feedback combined with a higher fidelity in the loss of resistance technique and better simulating tactile feel of encountering the ligaments, tissues, and bone involved in neuraxial technique. The ideal partial task trainer for neuraxial technique training would combine the physical and anatomic fidelity of manikins with the visuospatial feedback advantages and tactile fidelity found in computer-based models. More recently, haptics have been incorporated with virtual reality and gamification features 9,10 in an effort to enhance skill acquisition and trainee motivation. The use of a virtual environment now can achieve a higher degree of fidelity in recreating the clinical environment while retaining the fidelity in the tactile sensation of spinal or loss of resistance technique that haptics can provide. Gamification (scoring points and achieving increasing experience levels) increasingly is incorporated into both partial task simulation training and more complex multidomain clinical skills acquisition. 11 Capogna and colleagues 12 asked novice trainees engaged in simulated epidural technique training to wear eye-tracking glasses. Although epidural procedure duration and number of attempts decreased following a simulation-based training tutorial, they also found a positive correlation between the number of needle-insertion attempts and gaze fixation counts along with a negative correlation between epidural attempts and gaze duration. Over the past decade, an increasing volume of research has supported the use of high-fidelity manikin-based simulation for the anesthetic management of the maternal airway and obstetric emergencies. Exposure to high-fidelity simulation in conjunction with traditional lecture-based learning has been shown to enhance trainee performance in emergency management of an obstetric emergency requiring general anesthesia to the competency normally only seen in a fully trained faculty member utilizing a previously validated scoring system with significant retention 8 months following the initial assessment. 13, 14 A large volume of scenarios for anesthesia training for obstetric emergencies has been published for educators, including high spinal anesthetic level, 15 maternal cardiac arrest, 16 and a variety of other conditions. 5, 17, 18 Clinton and Minehart provided a roadmap in 2020 for the development of comprehensive simulation curriculum for advancing clinical skills with the inclusion of sample scenarios ( Table 1) . Simulation-based training has continued to show effectiveness in learning and retention of skills essential for the practice of obstetric anesthesiology, such as airway management during emergent cesarean delivery, 19 recognition and management of high neuraxial blockade, 20 and management of a general anesthetic for cesarean delivery. 21 The instruction of communication skills increasingly has been addressed through the use of simulation-based training. Raemer and colleagues 22 explored the role of simulation in overcoming the traditional hierarchical mode of communication within the health care workspace. To promote the ability of residents to speak up on identification of inappropriate clinical behavior on the part of faculty obstetricians, anesthesiologists, and labor and delivery nursing staff, 2 simulated clinical scenarios were provided to allow for the practice of the advocacy-inquiry and 2-challenge inquiry techniques. They found an increase in appropriate challenging behavior from 27% to 67% following post-simulation exposure. 22 More recently, Szmulewicz and colleagues 23 utilized interdisciplinary simulation-based training for the disclosure of a medical error to patients. This work showed trainees' improvement in both verbal and nonverbal communication skills with retention up to 6 months following the intervention. 23 (continued on next page) Advances in both Web-based and communication technologies increasingly have been integrated into simulation education for trainees, removing the need for both trainee and instructor to be in the same location. Telesimulation has become a tool to provide training of technical and nontechnical skills around the world. The use of telesimulation was described by educators in Canada to teach trainees in Botswana laparoscopic surgical technique with nothing more than a simple trainer box, a Web camera, and a laptop computer. 24 A randomized trial conducted by Sorenson and colleagues 25 in 2017 compared simulation-based obstetric anesthesia training in clinical management of an emergency caesarean section and a postpartum hemorrhage (PPH) scenario with in situ simulation versus off-site simulation. They found similar individual and team outcomes in patient safety attitudes, stress, motivation, perceptions of the simulations, and team performance while those receiving in situ simulation training did find a greater degree of fidelity than those receiving remote training. Given the success found in telesimulation-based training in both technical and nontechnical clinical skills acquisition, remote teaching may be an exciting frontier for the teaching of neuraxial technique or anesthetic management of obstetric emergencies by international experts to trainees around the world. Recent work by Lim and colleagues, 26 showing that mental imagery training can be used to develop epidural anesthesia technical skills as effectively as low-fidelity haptic simulators, even may suggest that effective remote education could be provided with only a Web camera. Simulation-based skills assessment has continued in line with advances in training. Kiwalabye and colleagues 27 assessed preparedness of anesthesia interns in managing a failed obstetric intubation following their anesthesiology rotation. They observed a pass rate of only 40% despite prior exposure to an Essential Steps in Managing Obstetric Emergencies training module, leading them to propose that this gap in skill acquisition discovered by simulated scenarios can be remedied through the use of simulation-based education during their training. An additional area in which simulation increasingly has been used in assessment lies in credentialing of those who have graduated from anesthesiology training programs. Since 2018, the American Board of Anesthesiology has included Objective Structured Clinical Examinations (OSCEs) as part of the APPLIED examination, including simulated interactions with patients. Although the technical and clinical components of obstetric anesthesia practice currently are not among the topics included in the OSCEs, communication with the parturient is addressed in modules assessing informed consent and communication of medical errors. This has led many programs to integrate OSCE training into their residency curriculum to better prepare trainees for the process of credentialing. Dabbagh and colleagues 28 found an increase in the relative annual pass rate of anesthesiology residents following the integration of a preparation program, including mock OSCEs prior to the National Board of Anesthesiology certifying examination. Multidisciplinary team training for obstetric care and crisis resource management (CRM) has been well described in the simulation literature. 29 Although confidence in this approach as a means to improve patient outcomes has been shown by stakeholders, such as insurance companies, there has long been effort to link the utilization of simulation for team training to improvements in patient outcomes. 30 A recent review of simulation team training, including human factors components, has provided some insight into this long-standing goal of those engaged in the field. Five single prospective site studies investigating multidisciplinary obstetric simulation training, including CRM and reported outcomes in high-resource and low-resource countries, were identified. 31 Two showed a 34% reduction in maternal mortality and 3 a 41% to 50% reduction in blood transfusion, whereas cluster analysis revealed a 17% reduction in PPH incidence and a 37% reduction on weighted obstetrics adverse outcomes. Furthermore, there was a 15% reduction in maternal mortality in favor of trained teams and a reduction of neonatal deaths from 24 weeks during the first 24 hours of 83% in intervention sites compared with an 18% increase in control sites. Lutgendorf and colleagues 32 conducted 16 multidisciplinary simulated scenarios, including PPH over 2 days to assess team performance and operational readiness. A comparison of PPH incidents in their institution revealed a decrease in the time to prepare blood products over the course of simulation training and a trend toward a reduction in the incidence of PPH. 32 These important results only increase the need for further work exploring the impact of simulation-based team training on obstetric patient and neonatal outcomes. Although work continues in the field of developing simulation-based team training curricula, 33 several studies have investigated team behavior through the use of Updates on Simulation in Obstetrical Anesthesiology simulation. A recent prospective observational study utilized individual personality testing to find associations with overall assessments of teamwork and communication in simulated management of PPH. The investigators discovered that a high degree of neuroticism among individual team members led to increased communication in a manner that was detrimental to overall team performance whereas other personality traits yielded no associations. 34 Capogna and colleagues 35 had team leaders of a simulated PPH scenario wear eye-tracking glasses to find associations between eye-tracking metrics of 27 selected areas of interest and team performance evaluated by a PPH checklist. Their group found that high-performance leader groups were associated with a greater duration of visual fixations as well as a more uniform distribution of gaze on team members compared with the low-performance leader groups. Methods of evaluating teams during obstetric emergencies, such as PPH, continue to evolve as more evidence is brought to bear on the importance of nontechnical skills, such as cognitive and social factors. Toward this end, Cheloufi and colleagues 36 employed a multidisciplinary Delphi method consisting of 4 cycles with 16 experts, including obstetricians, midwives, and anesthesiologists to create the Obstetric Team Performance Assessment Scale to be utilized during assessment of team performance during high-fidelity simulation exercises. This scale, based on expert consensus, emphasized the value of nontechnical skills, such as situational awareness and requesting help from the anesthesia team, in addition to traditionally identified checklist items, such as intravenous access and prompt activation of transfusion protocols. This work reflects the increased emphasis on the psychometric and social factors in the role of team performance being better understood through simulation. Hemorrhage remains a leading cause of death in parturients and an area of interest in developing protocols for quantification and management of blood loss. Simulation has been used effectively to assess the accuracy of different methods of blood loss quantification. The use of a pictorial guide as a means to assess blood loss during a simulated cesarean delivery was evaluated by Homcha and colleagues 37 comparing assessments of blood loss prior to and after use of the guide. Prior to use of the pictorial guide, they observed a more than 25% overestimation of blood loss, whereas use of the guide revealed an increase from 7% to 24% of accurate estimation defined as an estimate within 5% of the actual volume lost. Piekarski and colleagues 38 sought to compare a mobile colorimetric application for blood loss estimation with visual and gravimetric methods utilized by 53 anesthesiologists exposed to a simulated PPH scenario. They found the least deviation in estimates from the actual volume of blood loss among the colorimetric estimation followed by gravimetric and visual methods, whereas overestimation of blood loss occurred most in the visual estimation followed by the gravimetric and colorimetric methods. The risk of chlorhexidine contamination of materials introduced to the neuraxial space motivated Taylor and colleagues 39 to conduct a simulated study to identify the incidence of transfer of chlorhexidine from the lumbar region to standard surgical gloves in a study simulating standard lumbar region antiseptic preparation. Their findings revealed an incidence of primary transfer above 99% up to 10 minutes following chlorhexidine application to the lumbar region of volunteers, with a 68.9% incidence of secondary transfer from gloves to another surface. To evaluate the effectiveness of current Society for Obstetric Anesthesia and Perinatology (SOAP) Patient Safety Committee proposals to utilize a cap and run approach (capping epidural and intravenous lines to prevent tangling prior to transfer) to facilitate transport of patients from the labor room to operating theater during emergency cesarean deliveries. Mhyre and colleagues 40 utilized a prospective randomized in situ simulation study. They found no statistically significant difference in the time from decision to proceed with cesarean delivery to readiness for general anesthesia between groups, although qualitative analysis during debriefing did reveal some perceived advantages, such as bed maneuverability and a decrease in tangled lines. Efforts in low-income and middle-income nations to decrease maternal mortality hold great promise, given the ongoing discrepancy with rates observed in high-income nations. Simulation continues to play a large role in both education and developing or assessing initiatives aimed at improving maternal care. Alexander and colleagues 41 used the simulated setting to pilot test a context-relevant safe anesthesia checklist for cesarean delivery in East Africa. By comparing anesthesiologists providing care for a variety of conditions in the simulated environment with and without a checklist developed in conjunction with East African health care professionals, they found a significant increase in the completion of critical actions in the setting of preeclampsia and PPH. Gallardo and colleagues 42 utilized the simulated environment and a randomized crossover design, including 10 trainees, to compare the performance of trainees in simulated high-resource and low-resource environments managing PPH from uterine atony. They found a significant decrease in performance by those exposed to the simulated low-resource environment, including both technical and nontechnical skills, including leadership, resource utilization, and communication. The COVID-19 pandemic has radically altered the landscape for clinicians and educators across the world, and the invaluable role of simulation came to the fore in the field of obstetric anesthesiology. With direct patient contact and in-person teaching limited by social distancing requirements and infectious risk mitigation, simulation provided opportunities for medical students and anesthesiology trainees to learn both technical and nontechnical clinical skills. To accelerate education for management of critical events in the context of patients infected with COVID-19, high-fidelity simulationbased individual and team training proved invaluable. Most importantly, with the need to develop new work environments and processes, simulation technology served to test their feasibility and prepare health care systems and medical staff. Trainees found their ability to attain obstetric anesthesiology skills and knowledge limited by the fact that patient care brought a level infectious risk not previously common to the labor and delivery unit. In-person teaching also was impacted by requirements for social distancing imposed on training programs. Although the surgical volume elsewhere in hospitals decreased profoundly by the cancellation or delay of all but the most urgent surgical procedures, such measures could not be taken in labor and delivery units, and the need for clinical care remained relatively unaffected. Training programs leveraged simulation technology, such as partial task trainers, to provide exposure to neuraxial technique given the need for personal protective equipment (PPE) during patient interactions and limited exposure to parturients with known or suspected COVID-19. 43 Simulation also was described as a mechanism for training difficult airway management, PPE protocols, aseptic technique, and airway management. Virtual reality with gamification features also was described as a tool for approaching the maternal airway. Previously routine interactions with patients changed dramatically during the pandemic, necessitating rapid training of health care providers to mitigate the risk of infection to providers and patients. Professional societies turned to in situ Updates on Simulation in Obstetrical Anesthesiology multidisciplinary simulation as a resource for physicians and other health care professionals early in the pandemic. The American College of Obstetricians and Gynecologists Simulations Working Group created 4 standardized scenarios for use to guide multidisciplinary teams in patient interactions during the pandemic: (1) an obstetric patient with suspected COVID-19 presenting in labor; (2) an obstetric patient with suspected COVID-19 progressing in labor to spontaneous vaginal delivery, (3) an obstetric patient with suspected COVID-19 in labor requiring cesarean delivery; and (4) an obstetric patient with suspected COVID-19 requiring intensive care unit transfer due to worsening respiratory symptoms. 44 SOAP provided a scripted simulation scenario designed to guide teams through meeting a parturient with suspected COVID-19 team in triage, transport to a labor room and placement of a labor epidural, emergency cesarean delivery, induction, and recovery from a general anesthetic (Fig. 1) . 18 Simulation has been proposed as a mechanism for addressing novel scenarios brought about the pandemic, such as donning and doffing of PPE, transport of infected obstetric patients, management of a second obstetric emergency when the team currently is caring for an obstetric patient, approaches to the delay of an emergency cesarean delivery due to infection prevention and control measures, and communication with patients or families about visitation policies impacted by infection prevention and control measures. 45 Simulation scenarios also have been described to include not only multidisciplinary care of the obstetric patient but also neonatal care based on variable maternal COVID-19 status and symptomatology and gestational age at the time of delivery. 46, 47 The COVID-19 pandemic required major changes to not only workflow but also patient care areas in efforts to maximize infection prevention and control while providing patient care. Simulation served as the means for testing and revising these changes in real time throughout the world. Lie and colleagues 48 reported the use of plan-do-study-act cycles incorporating simulation to identify process threats, infection control threats, and equipment or PPE issues and then modified their COVID-19 patient care workflow based on their findings. Wong and colleagues 49 utilized simulated drills to test the feasibility of changes to their operating room setup and workflow. Findings based on these drills led to the designation of an operating room coordinator to ensure adherence to the protocol they had developed. Muhsen and colleagues 50 describe major changes made to their maternity ward floor plan, introduction of radio communications, and increases in staffing following simulation training sessions in preparation for care of COVID-19 infected obstetric patients. Other groups describe the use of simulation as part of the development of anesthetic care-specific checklists and protocols, including labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of a labor epidural to cesarean delivery, and general anesthesia for the obstetric patient. 51 One group incorporated actual obstetric patients into live simulation drills by providing their care as if they were patients infected with COVID-19, to test preliminary protocols designed for care of obstetric patients infected with COVID-19, and cited positive reactions from the patients involved. 52 Although the COVID-19 pandemic served as a crisis that showcased the value simulation brings to education, training, and preparedness in the field of obstetric anesthesiology, the limits placed on human interaction due to social distancing requirements accelerated the shift in learning and communicating to the virtual environment. The seeds of this evolution in the world of simulation existed prior to the pandemic, and recent literature provides a rough sketch of the world of simulation that may come into existence in the future. A recent review of alternatives to high-fidelity simulation by Delisle and colleagues 53 describes many of the modalities that do not require inperson training with partial task trainers or high-fidelity manikin-based simulation. Telesimulation allows for remote observation of a simulation scenario with live remote debriefing extending the geographic reach of a single simulation session for learners separated by vast distances. Screen-based simulation removes the need for a live instructor through the use automated facilitation and feedback mechanisms. Gamebased simulation, much like screen-based simulation, removes the requirement of a live instructor but also incorporates motivational aspects that exist in popular single-player or multiplayer videogames and can incorporate both technical and nontechnical skills. Improvements in virtual reality technology will allow game-based simulation increasingly to approach or surpass the fidelity of existing manikin-based simulation technology. Benda and colleagues 54 utilized an obstetric scenario to compare the educational effectiveness of serious game training to high-fidelity manikin-based training. Groups randomized to manikin-based or serious gamebased training prior to an assessment of performance in a high-fidelity manikin-based simulation scenario showed no difference in overall performance. Although the role of simulation in training and assessment of individuals, multidisciplinary teams, and the work environment in obstetric anesthesiology continued at the end of the second decade of the twenty-first century, the COVID-19 pandemic provided the ideal circumstances to reveal the unparalleled value simulation brings to training and preparation for emergencies, both locally and globally. Ironically, this turbulent period of pandemic health care, in which high-fidelity, team-based simulation has shone so brightly, likely will accelerate the transition toward alternative modes of simulation-based training and assessment through the increased use and capability of virtual platforms and screen-based learning environments. Simulation in obstetrical anesthesia should continue to be utilized to teach and to assess the competencies of the individual, the group and the institution at large. The COVID-19 pandemic showcased the ability of simulation in obstetrical anesthesiology to evolve and to address new and unprecedented emergencies within the obstetric unit. Simulation in obstetrical anesthesia will continue to evolve as technology advances and as the world encounters new medical challenges. The authors have nothing to disclose. Simulation in obstetric anesthesia Recent trends in simulation for obstetric anesthesia Simulation for anesthesia in obstetrics Recent advances of simulation in obstetric anesthesia Comprehensive healthcare simulation: anesthesiology Simulation in obstetric anesthesia: an update A greengrocer's model of the epidural space A review of epidural simulators: where are we today? 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