Case Study
A fit and well nulliparous woman at 34 weeks’ gestation presented to the delivery suite with her fetus in an incomplete breech position and threatened preterm labor. Soon after arrival, she felt a gush of fluid and “something between [her] legs.” The labor nurse immediately examined the patient and identified a cord prolapse.
The labor nurse shouted for help, explicitly indicating a cord prolapse, and also calmly informed the patient of the seriousness of the situation. Providers from anesthesiology, obstetrics, and nursing quickly arrived. The obstetric resident was only partially successful in relieving the cord obstruction. An anesthesiology team member went to ensure that the operating room (OR) was prepared, including informing the scrub nurse and neonatal team. The patient entered the OR within 1 minute of prolapse identification. A provider identified herself as the “event manager” and proceeded to clearly announce updates and ask specific questions, such as whether the cord had a palpable pulse. The obstetric resident replied that the pulse was not strong. The event manager alerted the room of the plan for emergency cesarean delivery, and the anesthesiologists proceeded with general anesthesia. Incision was made 2 minutes after OR arrival, and an active, crying male infant was delivered with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The patient emerged uneventfully and had an uncomplicated postoperative course. After a brief stay in the neonatal intensive care unit, the infant was discharged home with his mother.
The patient commented that despite her son’s potentially devastating condition and her fears for his safety, she felt full trust and confidence in the team and that they were all working together to help her.
Key Points
This patient experienced an obstetric crisis. If care were delayed or disorganized, this could have led to a disastrous outcome.
Such teamwork does not usually occur spontaneously but is manifested via deliberate education and training in crisis-management principles, ideally in multidisciplinary teams using high-fidelity simulation to teach concepts and behaviors.
Discussion
The field of obstetrics poses unique challenges to effective team performance and communication. For a patient in the delivery ward, providers from multiple healthcare disciplines are involved, including anesthesiologists, obstetricians, midwives, nurses, neonatologists, and other specialists. The number and variety of staff make interdisciplinary teamwork a challenging but critical necessity. In addition, pitfalls arise from the false sense of security that obstetric patients are generally young and healthy, because they may not exhibit deterioration until the situation is late and urgent.1
Poor teamwork on the obstetrics ward can lead to devastating consequences. Several reports have shown that better teamwork and communication could have prevented maternal morbidity, including hysterectomies, multiple organ dysfunction, coma, shock, and intensive care admission.2 Observations of simulated maternal cardiac arrests highlight common weaknesses in team performance, including slow problem recognition, delayed cardiopulmonary resuscitation, and poor communication.3 Poor multidisciplinary teamwork can also have a negative impact on the fetus and neonate. Suboptimal communication, poor teamwork, and deficient team training contribute to the most common root causes for infant death in the developed world.2 Optimal teamwork is essential in the management of high-risk delivery scenarios such as abnormal fetal heart rate and shoulder dystocia.2 With the potential for a rapid decline in maternal and/or fetal stability, obstetric care necessities that a multidisciplinary team be able to perform immediately, work well together, and communicate effectively.1
Crisis-management principles were initially adopted for anesthesiology by David Gaba in the 1980s. This approach uses principles from high-reliability organizations (HROs) such as the military, aviation, and nuclear power industries. Like high-stakes patient care, HROs have the potential for catastrophic outcomes, crisis time constraints, multiple decision makers, and complex communication networks yet use principles to operate nearly error free.1 HROs foster collective mindfulness, meaning that everyone in the organization is on high alert for safety threats and aware that small process failures could create devastating errors. At the core of HROs are five key concepts essential for safety1:
Sensitivity to Operations: aims to maintain situational awareness for potential errors.
Reluctance to Simplify Tasks: avoids introducing new errors from bypassing standardized steps.
Preoccupation with Failure: uses “near misses” as positive opportunities to analyze process weaknesses and build improvements into the current system.
Deference to Expertise: recognizes that the person with the most relevant knowledge may not be the person with the most expertise and hence a team approach is critical for sharing information.
Resilience: acknowledges that systems may fail in unanticipated ways and that staff must be prepared to perform quick situational solutions.1
As described in To Err is Human, an estimated 98,000 Americans die each year as a result of medical errors.4 Among patients admitted to a labor and delivery floor, Forster observed 110 triggers (events likely to indicate an actual or potential adverse event) in a prospective cohort study of 425 obstetric patients at a tertiary care academic hospital. Notably, poor teamwork and protocol violations were identified as the most important contributing issues, whereas technical proficiency and therapeutic decision making were less important.5 Similarly, other studies reveal team communication failures as the most commonly avoidable factor.6, 7 In a survey study of more than 1,000 healthcare workers, the most common recommendation to improve patient safety was “improved communication.”8
How can a team communicate well? Under time pressure and the high stakes of obstetric cases, a communication style that allows quick and efficient information sharing and critical feedback is key. Whereas an advocacy style of communication declares an opinion, an inquiry style elicits information.8 A balanced use of both advocacy and inquiry by both obstetricians and anesthesiologists may lead to better shared understanding during a crisis.8 Effective communication tools can also include structured methods for patient handoffs and checklists for information sharing.9
In addition to communication, what promotes good multidisciplinary teamwork? Salas10 proposes five key dimensions of effective teams:
Team leadership
Mutual performance monitoring
Backup behavior
Adaptability
Team organization
Studies show that team leadership is best established by the person who has the most experience with this type of emergency and when that person clearly states that he or she is assuming the manager role, as seen in the Case Study.2 Mutual performance monitoring allows identification of task overload, whereas backup behavior requires sufficient understanding of others’ tasks to support them when needed.9 Adaptability is similar to the HRO concept of resilience. It is possible that the system may fail in unexpected ways, and the team must be prepared to devise alternative solutions. Clear team organization may be hindered by shift changes and unfamiliarity with new team members. Introductions at the start of each shift are suggested so that staff can know team members’ names, roles, and experience levels in order to efficiently allocate tasks in an emergency.11
In addition, an effective multidisciplinary team also includes the patient. Almost one-fifth of women cite dissatisfaction with their labor and birth experience, particularly in emergency situations or after intervention becomes necessary.2 Therefore, it is crucial to train team members to communicate not just with each other but also with the patient and/or her supporters. As illustrated in the Case Study, the team ensured that the patient was aware of the seriousness of her situation and that she felt informed and included in her own care.
In addition to the five dimensions of effective teamwork set forth by Salas, good teams are coordinated by underlying mechanisms of mutual trust, shared mental models, and closed-loop communication. Mutual trust forms from rapport with team members and from familiarity with each other’s roles, expertise, and prior experiences.11 A shared mental model is a critical foundation for effective teamwork. Given the compressed timeline in a crisis, it is valuable to have the same mental framework regarding patient management, medical issues, and allocation of staff and resources. It is important for staff to identify the problem early and to verbalize information loudly to the entire team so that everyone has a shared view and can provide information to support or refute that view. Closed-loop communication ensures that essential instructions are correctly interpreted and performed by identifying the recipient by name or touch and then confirming that the task has been performed. This directed communication is associated with fewer errors, less work, less noise, and better team efficiency.2
It is also important to be aware of factors that could have a negative impact on the success of a multidisciplinary team. The social identity theory of the tribal phenomenon suggests that group members of one specialty may perceive other groups’ attributes as less desirable.9 This can create tension and communication barriers when multidisciplinary teammates have different expectations about how things should be done.9
Additional potential psychological barriers may exist in hierarchical structures, with less senior staff reluctant to offer suggestions or challenge decisions. Weller et al.9 set forth several interventions to overcome barriers to information sharing. Teams should be redefined as inclusive rather than specialized silos. Creating democratic teams allows each team member to feel valued and able to communicate information.
Finally, the bedrock for effective multidisciplinary teams is an organizational culture that champions patient safety. Whereas safety culture can be defined as the integration of safety practices into clinical activities, safety climate is a quantitative description of this culture. This quantitative approach uses outcome measures such as adverse events and adherence to processes or cultural measures such as attitudes toward patient safety. By asking staff to respond to statements such as “The staff works together as a well-coordinated team,” questionnaires can help explore differences in perspective, such as the level of teamwork culture perceived by nurses, residents, obstetricians, and anesthesiologists in the department.12
In the pursuit of effective multidisciplinary team management, simulation can be a valuable modality to develop, reinforce, and research ideal crisis-management behaviors (Figure 13.1). Simulation provides an opportunity for participants to explore communication styles and to better understand other roles within the team.13 During simulation, it is important to also consider threats to positive learning environments, such as preexisting tensions. Sufficient representation by all groups is needed to effectively model a multidisciplinary case and to yield valuable discussions around multidisciplinary team processes. Good facilitation is critical for creating a supportive atmosphere and a valuable debriefing discussion14 (Figure 13.2).