Teaching an Experienced Multidisciplinary Team About Postpartum Hemorrhage: Comparison of Two Different Methods

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1 EDUCATION Teaching an Experienced Multidisciplinary Team About Postpartum Hemorrhage: Comparison of Two Different Methods Mary Higgins, MD, 1,2 Julia Kfouri, MD, 1,3 Anne Biringer, MD, 4 Gareth Seaward, MD, 1,3 Rory Windrim, MB 1,3 1 Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto ON 2 Department of Obstetrics and Gynaecology, School of Medicine and Medical Science, University College Dublin, National Maternity Hospital, Dublin, Ireland 3 Department of Obstetrics and Gynaecology, University of Toronto, Toronto ON 4 Department of Family and Community Medicine, University of Toronto, Mount Sinai Hospital, Toronto ON Abstract Objective: Morbidity from postpartum hemorrhage (PPH) affects 20% of pregnancies worldwide and remains a significant cause of maternal mortality. This study compared the impressions of experienced clinicians on the effect of two methods of educational interventions in a More OB training program designed to improve recognition and management of PPH. Methods: Participants were exposed to a traditional didactic lecture and an interactive clinical intervention exercise incorporating video simulation of a PPH event with opportunities for feedback and discussion of how to proceed. They were then invited to respond to a questionnaire regarding their impressions of both methods. Results: Of 150 participants, 110 completed the questionnaire. Respondents considered the interactive format to be more effective (55%) and enjoyable (72%) than the traditional didactic format. The majority (81%), however, still recommended a mixture of both interactive and didactic formats in future events, supported by a multidisciplinary drill. Conclusion: Clinical learners value interactivity and mutual reinforcement among varied learning exercises in their educational experiences. Future educational programs may consider incorporating similar methods in order to maximize participants receptiveness. Key Words: Postpartum hemorrhage, More OB, training, casebased intervention Conflict of Interest: None declared. Received on September 14, 2014 Accepted on November 28, 2014 Résumé Objectif : La morbidité attribuable à l hémorragie postpartum (HPP) affecte 20 % des grossesses à l échelle mondiale et demeure une cause importante de mortalité maternelle. Cette étude a comparé les impressions de cliniciens expérimentés quant aux effets de deux méthodes d intervention pédagogique (dans le cadre d un programme de formation AMPRO OB ) conçues pour améliorer la reconnaissance et la prise en charge de l HPP. Méthodes : Les participants ont pris part à un exposé magistral traditionnel et à un exercice interactif d intervention clinique alliant la simulation vidéo d un événement d HPP à des occasions de formuler des commentaires et de participer à des discussions sur la façon de procéder. Nous les avons par la suite conviés à répondre à un questionnaire au sujet de leurs impressions quant à ces deux méthodes. Résultats : Cent dix des 150 participants ont rempli le questionnaire. Les répondants étaient d avis que le format interactif était plus efficace (55 %) et plaisant (72 %) que le format magistral traditionnel. La majorité d entre eux (81 %) ont cependant recommandé l offre d une approche mixte intégrant les deux formats dans le cadre des événements à venir, le tout devant alors être soutenu par la tenue d un exercice d entraînement multidisciplinaire. Conclusion : Dans le domaine clinique, les apprenants accordent de l importance à l interactivité et au renforcement mutuel de divers exercices d apprentissage dans le cadre de leurs expériences pédagogiques. Les futurs programmes pédagogiques pourraient envisager l intégration de méthodes semblables afin de maximiser la réceptivité des participants. J Obstet Gynaecol Can 2015;37(9): SEPTEMBER JOGC SEPTEMBRE 2015

2 Teaching an Experienced Multidisciplinary Team About Postpartum Hemorrhage: Comparison of Two Different Methods INTRODUCTION Postpartum hemorrhage (PPH) remains a significant cause of maternal mortality and morbidity. It affects nearly one fifth of deliveries worldwide and is the major cause of peripartum hysterectomy. 1 In Canada, 28 women died between 1981 and 2004 as a result of postpartum hemorrhage (ratio between 1.4 and 5.3/ live births), making it the third most common cause of maternal mortality in the country during that time. 2 More recently, the incidence of PPH leading to maternal mortality appears to be increasing, such that the 2013 maternal mortality rate for postpartum hemorrhage is 1.8 per deliveries in Canada (excluding Quebec), 3 although the difference in reported denominators limits comparison. After years of intense training and education, the incidence of PPH as a cause of maternal mortality in the United Kingdom had reduced; in the Centre for Maternal and Child Enquiries report published in 2011, the number of deaths following PPH had reduced from 17 in the triennium 2000 to to nine. 5 At that time, in six cases either minor or major degrees of substandard care were identified. More recently, the mortality from PPH in the United Kingdom and Ireland has increased to 17 maternal deaths (between 2009 and 2012) in the new report, highlighting the need for continued education and awareness. 6 In addition, both nationally and internationally, PPH persists as a cause of significant maternal morbidity. In Ireland, major obstetric hemorrhage is the most common cause of maternal morbidity, affecting two women in every 100 deliveries. 7 Postpartum hemorrhage may be defined as either blood loss of more than 500 ml (1000 ml after Caesarean section) from the genital tract after delivery, or blood loss sufficient to cause signs or symptoms of hemodynamic compromise. 1 The morbidity following a PPH can occur immediately (requirement for blood transfusion, coagulopathy, renal failure, need for emergency surgery or hysterectomy) or later (Sheehan s syndrome, post-traumatic stress syndrome or effects on future fertility). 8 Because of the significant morbidity and mortality associated with PPH, and also because it remains one of the most common complications of delivery, there is an onus on clinicians within the multidisciplinary team to remain up to date in their training in how to most effectively recognize and manage a PPH. Experts agree: one of the top ten recommendations of the last Centre for Maternal and Child Enquiries report referred to clinical skills and training, calling for all clinical staff to undertake regular, written, documented and audited training for the identification and initial management of serious obstetric conditions. 5 This is also reflected in South Africa, where Hemorrhage and Health Worker Training are recommended as two of the five key points aiming to reduce possibly and probably preventable maternal deaths. 9 Studies have examined the short-term effects of simulation, video, 13 drills, 14 and assessment of long-term retention of data following educational interventions 12,15 ; all have shown improvements in both confidence and knowledge in recognition and management of PPH after these interventions. In addition, team performance and medical technical skills may be significantly improved after multiprofessional obstetric team training. 16 We are unaware of any studies assessing the effect of different in-house educational interventions for PPH within Canada. More OB is a structured educational resource that is widely used in Canada and in other countries, and that provides an evidence-based structure for continuing education for nurses, midwives, family practitioners, and obstetricians working with pregnant women. 8 The More OB course is provided with online modules and yearly in-house updates based on course content. 17 This study was carried out to examine how experienced clinicians viewed the effects of two different methods of delivering information on recognition and management of a PPH within a More OB workshop. METHODS Mount Sinai Hospital is a tertiary level unit in Toronto, Ontario, providing obstetric care for 7500 births in an ethnically diverse population. Permanent clinical staff (nurses, midwives, obstetricians, and family doctors) are all enrolled in the More OB program, with annual workshops focused on preparation for obstetric emergencies. Staff members attending the workshop were invited to participate in a study evaluating different educational methods of teaching the recognition and management of PPH. All participants were exposed to the different educational interventions. As this was a mandatory session for permanent staff, the content was based on the More OB module on PPH. Those consenting to the study completed a questionnaire assessing their opinion of two education methods used to teach PPH. The first, a traditional didactic lecture, reviewed the information on PPH using the information from the More OB online course. The second, an interactive video presentation, brought participants through a typical PPH scenario, with time to allow for discussion at key points and to apply the findings to the local setting. 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3 Education video was based on the following scenario: A 33-yearold woman, G5, P4, with no previous medical or obstetric risk factors has a very rapid two-hour labour. Within 10 minutes of arriving on the labour ward she delivers a healthy vigorous male infant weighing 4090 g. Her midwife was in the hospital attending to another woman and was able to attend to her quickly. The woman had previously requested no active management of labour, and this had been documented after detailed discussion. The scenario then led the participants through the risk factors for PPH, the recognition by the midwifery team of the impending PPH, their initial management, the involvement of the obstetric, nursing, and anaesthesia teams, and the eventual resolution of the PPH after management in the operating room. Options regarding the medical and surgical management of the patient were suggested to participants in order to stimulate discussion. At pertinent points in the presentation, videos were shown of key clinicians within the Mount Sinai unit commenting on the management to date of the scenario. These key clinicians included the nursing manager of the case room, a staff neonatologist, the head of the obstetric anaesthesia program, and the head of obstetrics. The videos concluded with a debriefing of the situation. Other than the comments by key staff members, the videos were filmed using actors, paid from an educational fund used to record common obstetric emergencies and used for training residents and staff. Ethics approval was obtained from the Clinical Ethics Committee at Mount Sinai Hospital. RESULTS One hundred ten participants consented to complete the questionnaire, representing 73% of 150 original workshop participants. When questioned, the majority considered the interactive format to be more effective (55%, n = 60) and enjoyable (72%, n = 80) than the traditional didactic format. Despite this, when asked to recommend formats for future courses, most (81%, n = 90) recommended a mixture of both interactive and didactic formats, supported by a multidisciplinary drill. Of the remainder, four (3.6%) recommended a didactic format alone, and 16 (14.5%) recommended an interactive format alone. Different themes were identified on analysis of participants comments. While some participants preferred the interactive scenarios ( application of knowledge allows for greater understanding and fills gaps in knowledge, more stimulating, allowed more discussion, more fun, more memorable, engaging, funny and entertaining, would be more effective for a group of professionals with sound baseline knowledge to further develop expertise ), others focused on the advantages of the traditional didactic lecture ( allows for greater volumes of information to be conveyed, reinforced previous experiences, traditional works better for new staff to gain knowledge, the didactic format was methodological and covered all important areas ). Other than these personal preferences, a common theme was the value of using different but complementary educational methods to strengthen knowledge. Comments illustrating this included the traditional didactic was good to support the interactive scenarios, both are effective you must know the steps and then practise, and debriefing is very important, a little of each drives points home, all of them are effective they build well on each other. The information is important and it s good to learn it in different ways, you need to have both review basic theory and then do the hands-on situation. Participants were aware of different types of learning styles, with comments including they complement each other... you get to practise what you learn. People learn differently and this allows for most type of adult learners, as well as multiple formats give good interactivity. A final theme was the aspect of enjoyment of the morning session ( more enjoyable as everyone got to participate, video was entertaining and well put together, a fun way to learn, and broke up the time ), comments that are satisfying for any organizers of educational events to receive. DISCUSSION We found that experienced clinicians value a variety of educational interventions when providing updates of the recognition and management of PPH, a common and important complication of delivery. Whereas participants felt that the interactive method was more enjoyable and effective than the didactic sessions, a significant majority advised that future sessions should include both educational interventions, recognizing that different people have different educational needs. Other studies investigating the most effective method of teaching recognition and management of PPH have focused on simulation, 10 compared simulation to didactic lectures, 11,12 assessed the impact of staff education and drills, 14 and assessed long-term retention of data following educational interventions. 12,15 Currently in the Netherlands, a large countrywide study is being conducted to assess the rate of implementation of guidelines and educational interventions on the recognition and management of PPH, 826 SEPTEMBER JOGC SEPTEMBRE 2015

4 Teaching an Experienced Multidisciplinary Team About Postpartum Hemorrhage: Comparison of Two Different Methods as well as possible barriers to implementation. 18 The results of this study are eagerly awaited. While most previous studies have concentrated on the effect of simulation, some criticism has been raised citing the possible stressful nature of the process. Staff members have reported feeling as if they were on trial, and additional concerns have included time management in busy, under-resourced units, a lack of interest in multidisciplinary training, and the difficulties of providing service while drills were running. 19 Simulation may require clinicians to travel to a simulation laboratory, and can be expensive. When practical multiprofessional training is provided, the effects of educational interventions may be independent of location, with one study showing that while there was a significant increase in staff knowledge, there was no difference between the two locations where the program was run (local hospital and simulation centre). 12 It is for these reasons we chose to examine the effect of didactic versus interactive training within the clinical setting as part of a program offered nationally throughout Canada. Previous publications have described the requirements within an institution to make educational interventions as relevant as possible for the staff participating; these requirements include institution level incentives, relevant in-house training, non-threatening interventions for the entire workforce, and applicability of national problems to the local situation All of these were integrated within this study. The significant limitation of this study is that it reflects the opinions only of the participants. In a series of articles published in 1959, Kirkpatrick first described the four stage model of evaluation of educational interventions; these were then expanded in a 1996 publication. 23 These four stages are reaction (the participants opinion of the evaluation), learning (their increase in knowledge of the subject, skill set, or attitude), behaviour (their use of this knowledge or skill on the job), and results (the final outcomes that resulted from participation in the training program). Our study analyzed the educational interventions solely based on consenting participants opinions of the educational interventions. Originally the research team had planned to evaluate possible changes in knowledge after the interventions, but this was not included in the final evaluation because the difference in knowledge was predicted to be minimal because of the extensive clinical experience of the particular group. Future assessments of educational interventions would also assess acquisition of knowledge if a less clinically experienced group (such as medical students or junior residents) were to be included. As a project progresses through the Kirkpatrick stages, evaluation becomes more difficult and time-consuming. 24 Studies evaluating differences in clinical outcomes as a result of educational interventions have concentrated on countries or areas with a higher baseline rate of complications, such as in the developing world. For example, a study in Tanzania 25 focused on a two-day educational intervention in a centre with a high background rate of PPH. Here the educational intervention reduced the incidence of PPH from 33% to 18% following intensive education of staff, and the incidence of severe PPH fell from 9.2% to 4.3%. In the Mount Sinai unit the background incidence of PPH is low, and a multicentre study would be required to obtain sufficient numbers to identify meaningful differences in rates of PPH following an educational intervention. CONCLUSION This study aimed to evaluate different methods of educational interventions used to update experienced clinicians attending a mandatory in-hospital session on common obstetric emergencies. An interactive case-based intervention was rated by participants as being more effective and enjoyable than a traditional didactic lecture. Future sessions will be planned to include educational interventions of different types to attract different learning styles and to make sessions as effective and enjoyable as possible for a wide audience. ACKNOWLEDGEMENTS We wish to acknowledge the staff of Mount Sinai Hospital who participated in this study. The educational videos used in this study were created with financial support provided by a grant from The Network of Excellence in Simulation for Clinical Teaching and Learning, Ontario. REFERENCES 1. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva (CH): WHO; Available at: _eng.pdf. Accessed July 5, Public Health Agency of Canada. Canadian perinatal health report. Ottawa (ON): PHAC; Available at: publicat/2008/cphr-rspc/pdf/cphr-rspc08-eng.pdf. Accessed June 29, Public Health Agency of Canada. Maternal mortality in Canada in Perinatal_Health_Indicators_for_Canada_2013. Ottawa (ON): PHAC; Available at: REVISEDPerinatal_Health_Indicators_for_Canada_2013.pdf. Accessed June 29, SEPTEMBER JOGC SEPTEMBRE

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