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Immersive, cross-departmental simulation – mapping emergency obstetric care from admission to delivery

‘Translational’ simulation activities are effective at improving patient safety when directed towards a specific patient journey [1]. North Bristol NHS Trust cares for around 6,000 obstetric patients per annum, with around 1,000 infants delivered by unplanned caesarean section each year. The in-situ simulation presented here facilitated an in-depth exploration of our cross-departmental response to a hypertensive pregnant patient presenting to the Emergency Department (ED). Severe pre-eclampsia in a preterm patient is a complex clinical scenario which, akin to previous successes seen with trauma care, may benefit from simulation focused on teamwork behaviours. The potential for benefit was optimised by application of the ASPiH Standards for Simulation-Based Education [2].
 The aim of the simulation was to prospectively identify latent safety threats to emergency obstetric care in patients presenting to the Emergency Department at Southmead Hospital. An in-situ simulation was conducted to simulate a pre-term woman presenting with pre-eclampsia and reduced conscious level. The high-fidelity scenario involved collaboration from 28 staff in emergency medicine, radiology, obstetrics, neonatal medicine, anaesthetics, and theatres as the patient journey evolved, ending in emergency caesarean section in the non-obstetric emergency theatre complex. Members of the expert panel acted as passive observers to record an accurate log of events during the scenario. A formal debriefing was conducted at the conclusion of the simulation where participants were invited to discuss potential hazards arising from the scenario. Failure modes and effects analysis was employed to assess the identified latent risks [3].
 Ten latent safety threats were identified from the simulation. These were stratified according to severity and action plans were agreed to address them. Cross-departmental changes are being instigated and tested. These include amendments to emergency grab-bags, implementation of site-wide tools for location mapping in clinical emergencies, wider availability of the obstetric WHO checklist in emergency theatres, and clarification on the availability of blood for neonatal transfusion in non-obstetric theatres.
 This immersive scenario engaged clinical teams from a number of specialities and clinical areas across the hospital. Reflecting a real-life patient journey allowed for a rich and nuanced understanding of the response to an evolving emergency scenario. Cross-departmental collaboration in simulation-based training can be effective in assessing latent safety threats, particularly where staff operate in unfamiliar environments. Through carefully conducted debriefing, task allocation and follow-up, it is possible to diagnose and treat a broad range of latent threats to workflow, systems and processes.
 1. Brazil V. Translational simulation: not ‘where?’ but ‘why?’ A functional view of in-situ simulation. Advances in Simulation. 2017; 2(1):1–5.
 2. Association for Simulated Practice in Healthcare. Simulation-based education in healthcare: standards framework and guidance (2016).
 3. Davis S, Riley W, Gurses AP, Miller K, Hansen H. Failure Modes and Effects Analysis Based on In-Situ Simulations: A Methodology to Improve Understanding of Risks and Failures. In: Henriksen K, Battles JB, Keyes MA, Grady ML (Eds). Advances in Patient safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville(MD): Agency for Healthcare Research and Quality (US); 2008.