Biography

Tim Draycott is a Consultant Obstetrician in the UK with a research interest in patient safety, particularly multi-professional training, simulation, team-working and quality improvement in obstetrics. The aims of this research are to improve systems for clinicians involved in daily obstetric practice ensuring that the most appropriate methods are easy and convenient and are adopted by the entire obstetric team.

Dr Draycott is responsible for the development of the PRactical Obstetric Multi-Professional Training (PROMPT) course, which has been associated with improved knowledge, communication, team-working and direct improvements in perinatal outcome. It has been successfully rolled out in the UK and introduced into Hong Kong, Australia, New Zealand and the Pacific, as well as the US.

Dr Draycott is also leading the Research into Safety & Quality (RiSQ) Group who developed an automated maternity dashboard and a simple tool to measure maternal satisfaction after delivery. They have also introduced a series of simple and cheap decision support tools to improve care in labour.

Presentation

View the presentation "Latest developments in PPH training and management" by Dr Tim Draycott

Transcript

Slide1
Thank you, I am delighted to be here to present some of our data. I am going to talk about one of the latest developments and training that we can employ for post partum hemorrhage.

Slide2
"I can't stop the bleeding." Again and again and again we come against this situation. I think what we need to have a think about is how we can control bleeding, how we can train better, how we can train as teams to manage post partum hemorrhage in a better, more effective way.

Slide3
Just as Gian Carlo said, PPH rates are increasing and very interestingly the other point of those data is actually a type of PPH that is accounting for the vast majority of the increase.

Slide4
In the UK we see major obstetric hemorrhage in a number of different ways. It was defined in one Scottish study as more than 2,500 ml, more than five units transfused or a coagulopathy. It is the third most common cause of maternal death in the UK and that has remained the same over the last three or four triennia. The last three or four confidential inquiries in the UK have all confirmed that post partum hemorrhage is the third most significant cause of death.

Slide5
In fact 17 women died in the UK in the last three year period, and you can see that the majority of the women with caesarian section. I don't think that caesarian section causes PPH but we actually do a caesarian section as an emergency rescue often, do we not? Ethnic minorities, 2 out of 17 declined products, but look, more than half of them were thought to have been avoidable had their care been better. So even in a well developed, well structured, sophisticated country like the UK, more than half of all the deaths could have been avoided if they had been managed better.

Slide6
We saw the same problems again and again and again. People don't recognize the problem, they then don't do anything about it, and they don't refer. People ask too junior doctors to come have a look at things and very tellingly, poor, or non-existent, team working. I think that is one of the key issues we have to have a think about.

Slide7
We randomized our whole region in eight different hospitals to different sorts of training, and we identified four major issues in simulated post partum hemorrhage: delay in diagnosis, people didn't know where anything was in their department, no one knew where the blood was kept, no one knew where the drugs were kept, people made mistakes, people didn't use the right drugs. And again this issue of poor teamwork.

Slide8
And routine in the UK over all of the big UK recommendations, people have recommended regular training including teamwork, early warning scoring systems, I'll talk a bit about those, consider early recourse to experienced surgical help, particularly with placenta accrete now. I think we are certainly recognizing that yes, we need more experienced surgical help, and in particular multi-professional planning for placenta accreta.

Slide9
So how should we train? Well, unfortunately everyone's got an opinion about training. People say we should use simulation. Other people in the States say simulation is a total waste of time. Actually, the UK when it was surveyed, no one really knew what sort of training is most effective.

Slide10
There are many examples across the world of training that didn't make a difference. In the US the MedTeams OB study cost $20 million, randomizing 17 units to teamwork training or not, it made no difference to any outcome at all.

In Liverpool when they started training to manage PPH it didn't make any difference at all, and in Oxford, just published in the Green Journal, they showed, after they started training the shoulder dystocia they doubled the rate of brachial plexus injury. So not all training is equal. No all training is effective. We need to work out what works where.

Slide11
As I said we randomized our whole region. Why don't we test an assessed training in the same way as we test other obstetrical interventions? Why don't we do it in the same way, the same standard of proof? I live here, in the southwest of the UK

Slide12
We randomized our whole region to training in a hospital locally and training in the simulation centre, with or without extra team work training, and we videoed teams of six managing shoulder dystocia, post partum hemorrhage and eclampsia in their own units.

Slide13
What we found was that after training people improved. A lot improved their basic tasks, they got quicker to giving syntometrine. But what was interesting was there was no additional benefit of teamwork training, everybody's team work improved by working in teams. Just by running the drills in their own units people's teamwork improved by itself.

Slide14
We could demonstrate that the team work scores improved, as you can see. But what was interesting is those teams who had extra teamwork training, there was a reduction in the number of commands and inquiries. So people asked the right question directed to a person and there wasn't so much noise in the management. I think we do need to have a think about team working and I will discuss some elements of it.

Slide15
We have just recently reviewed all the obstetrical emergencies training currently published that have demonstrated improvement in outcomes. All of the teams, Copenhagen, who over here asked a group in the States, the MoreOB system in Canada, all of those systems have the same elements of training. All of them are in the actual units where the care is undertaken. All of them have a bit of teamworking, and they use realistic training tools. All of the effective systems aim for 100 percent participation. And they all have insurance-based financial incentives.

So I think we need to have a think about any training system that currently aims to improve hard outcomes for mothers and babies has these five elements to it, and that should be considered for all future training too.

Slide16
So, simulation PPH, well I'm not sure. She looks pretty unwell to me. That doesn't look too beautiful. This is Noel, University of Utah.

Slide17
This is in Auckland where people are training to assess how much blood loss there is.

Slide18
What we have been doing in our own unit, I'll show you some of our work, is early warning charts. What I would say is, I'll talk briefly about early warning charts because I know Professor Rath is going to talk about it too, one of the key things is to simplify the charts, and I'll show you that. I'll show you some of our work. The key thing for us is that our training is very, very, very cheap. The NHS has no money at all, I think we've got slightly more money than the Greek NHS, but I think that's about it. But actually it is very cheap and very effective. Now - look.

Slide19
Patient actresses. She is actually retired. She is one of our ex-midwives and we use her to do the post partum hemorrhage drill. She just generally bleeds to death, does very well. You don't have to plug her in, you don't have to put her in a cupboard afterwards. She goes home by herself. There are a number of advantages to using patient actresses. Here is one of the post partum hemorrhage drills. We put out red material here to simulate the blood, because actually it is a lot easier to clear up than real blood fluid.

Slide20
This is actually from Auckland where they use exactly the same thing. There is the blood coming out and they use 2 one-liter bags underneath the trousers, just fluid bags, to give you that feeling of an atonic uterus.

Slide21
We use these sheets, we are not allowed to use real blood in the UK, because that would be wasteful. In fact when we asked the hematology department could we have fake blood, they said "no, because someone might give it." And then we said, "well how about we make like blue fake blood?" They said "no, no, no, someone still might give it". Then you think, right, okay, this is a bad department you know. So we just photocopied some blood bags because you are trying to teach people not to manage the transfusion, but where to get the blood from to actually do the transfusion in an emergency. That is what you are teaching people.

This is doing resus in a water birth room. This is what the midwives call the big knickers. This is teaching people to make a decision for peri partum section at five minutes.

Now we are not teaching them how to do a section, we are teaching them to make the decision five minutes.

Slide22
This is what we use.

Slide23
We have for each of our drills a checklist for all the things you are meant to do during the drill, but we also have a teamworking checklist and we get one of the group to feedback themselves. I think you have got to be careful if a really famous professor, Professor Farine, comes to teach you how to do post partum hemorrhage and he is assessing you, there is quite an authority grading there. Sometimes it is worth structuring the feedback so people can feedback themselves using very structured forms. That is very non-intimidating and works very well in our department certainly.

Slide24
This is free. I want you to have a look at this. It is not very beautiful. This is a PPH simulator, a little bit of software, it is free. There is no book. You can give fluid, you can give blood. Now you can put the blood that stands up, no fluid goes in quicker. It is run on a physiological model. This is real physiology. This is free. The students absolutely love it. They feel like they are being real doctors. I recommend it. We use it for some of our drills to generate the numbers here. Now you can give drugs, there are drugs to give here. You can do an EUA. It tells you for example that you can't do an EUA until you have called in an anesthetist, seems sensible. And the anesthetic registrar comes quicker than the anesthetic consultant. So, it is very lifelike, in the UK anyway.

Have a think on that, it works really well, it's free, there is no instruction manual but you can download it from our website, and I will show you how to do that in the end.

Slide25
Early warning charts. This is our early warning chart. I'm at North Bristol NHS Trust here. One thing I would say to you is, I don't know if you have early warning charts I'm sure you do, the ones where you have to add up the numbers to get a score did not work in our department. People cannot add up to five. And in an emergency they go, "no, no, no, no, she's a three therefore she can't be unwell despite the fact that she's dying in front of you. Okay? So what we do is we just have amber and red bands, you have two ambers or one red, you call for help. And every single observation chart in our department has these bands on. Because we are trying to find the well woman who becomes unwell, not the one who is already on ITU. So every single observation chart in our department has these on.

Slide26
So look, PPH is common. We see it every day. We're not very good at it. We're not as good as we should be or could be. Training is often recommended but I recommend to you to think about local, cheap, multi-professional training that is effective.

Slide27
I am notoriously disorganized. If anyone wants to email me, I'm delighted. All the things I have shown you today are available to download on that website. So, if you want to download the early warning charts, if you want to download the PPH game, or any number of things, then feel free to download them for free.

Thank you very much.

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