MILITARY MEDICINE, 182, 3/4:e1762, 2017

Multidisciplinary In Situ Simulation-Based Training as a Postpartum

Hemorrhage Quality Improvement Project
Monica A. Lutgendorf, MD, FACOG*; Carmen Spalding, PhD†; Elizabeth Drake, RN, MSN‡;
Dennis Spence, PhD, CRNA§; Jason O. Heaton, MD, FACOG*; Kristina V. Morocco, MD, FACOG*

ABSTRACT Background: Postpartum hemorrhage is a common obstetric emergency affecting 3 to 5% of deliveries,

with significant maternal morbidity and mortality. Effective management of postpartum hemorrhage requires strong team-
work and collaboration. We completed a multidisciplinary in situ postpartum hemorrhage simulation training exercise
with structured team debriefing to evaluate hospital protocols, team performance, operational readiness, and real-time
identification of system improvements. Our objective was to assess participant comfort with managing obstetric hemor-
rhage following our multidisciplinary in situ simulation training exercise. Methods: This was a quality improvement
project that utilized a comprehensive multidisciplinary in situ postpartum hemorrhage simulation exercise. Participants
from the Departments of Obstetrics and Gynecology, Anesthesia, Nursing, Pediatrics, and Transfusion Services com-
pleted the training exercise in 16 scenarios run over 2 days. The intervention was a high fidelity, multidisciplinary in
situ simulation training to evaluate hospital protocols, team performance, operational readiness, and system improve-
ments. Structured debriefing was conducted with the participants to discuss communication and team functioning. Our
main outcome measure was participant self-reported comfort levels for managing postpartum hemorrhage before and after
simulation training. A 5-point Likert scale (1 being very uncomfortable and 5 being very comfortable) was used to mea-
sure participant comfort. A paired t test was used to assess differences in participant responses before and after the simu-
lation exercise. We also measured the time to prepare simulated blood products and followed the number of
postpartum hemorrhage cases before and after the simulation exercise. Results: We trained 113 health care profes-
sionals including obstetricians, midwives, residents, anesthesiologists, nurse anesthetists, nurses, and medical assis-
tants. Participants reported a higher comfort level in managing obstetric emergencies and postpartum hemorrhage after
simulation training compared to before training. For managing hypertensive emergencies, the post-training mean score
was 4.14 compared to a pretraining mean score of 3.88 ( p = 0.01, 95% confidence interval [CI] = 0.06–0.47). For
shoulder dystocia, the post-training mean score was 4.29 compared to a pretraining mean score of 3.66 ( p = 0.001,
95% CI = 0.41–0.88). For postpartum hemorrhage, the post-training mean score was 4.35 compared to pretraining
mean score of 3.86 ( p = 0.001, 95% CI = 0.36–0.63). We also observed a decrease in the time to prepare simulated
blood products over the course of the simulation, and a decreasing trend of postpartum hemorrhage cases, which con-
tinued after initiating the postpartum hemorrhage simulation exercise. Discussion: Postpartum hemorrhage remains a
leading cause of maternal morbidity and mortality in the United States. Comprehensive hemorrhage protocols have
been shown to improve outcomes related to postpartum hemorrhage, and a critical component in these processes
include communication, teamwork, and team-based practice/simulation. As medicine becomes increasingly complex,
the ability to practice in a safe setting is ever more critical, especially for low-volume, high-stakes events such as post-
partum hemorrhage. These events require well-functioning teams and systems coupled with rapid assessment and
appropriate clinical action to ensure best patient outcomes. We have shown that a multidisciplinary in situ simulation
exercise improves self-reported comfort with managing obstetric emergencies, and is a safe and effective way to prac-
tice skills and improve systems processes in the health care setting.

*Department of Obstetrics and Gynecology, Naval Medical Center San
Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
†Department of Medical Simulation, Naval Medical Center San Diego,
34800 Bob Wilson Drive, San Diego, CA 92134.
‡Department of Nursing, Naval Medical Center San Diego, 34800 Bob
Wilson Drive, San Diego, CA 92134.
§Department of Anesthesia, Naval Medical Center San Diego, 34800
Bob Wilson Drive, San Diego, CA 92134.
The views expressed in this article are those of the author(s) and do not
necessarily reflect the official policy or position of the Department of the
Navy, Department of Defense, or the U.S. Government.
Several of the authors are military service members. This work was
prepared as part of their official duties. Title 17 U.S.C. 105 provides that
“Copyright protection under this title is not available for any work of the
U.S. Government.” Title 17 U.S.C. 101 defines a U.S. Government work as
a work prepared by a military service member or employee of the U.S.
Government as part of that person’s official duties.
doi: 10.7205/MILMED-D-16-00030
INTRODUCTION
Postpartum hemorrhage is an important cause of maternal
morbidity and mortality in the United States. Appropriate
management of postpartum hemorrhage requires a compre-
hensive team effort to optimize care in an emergency. As
health care systems become increasingly complex, patient
safety systems, teamwork strategies, and medical simulation
have been shown to improve outcomes, and are recommended
as part of comprehensive patient safety programs in obstet-
rics.1–3 At our institution, we adopted a standard postpartum
hemorrhage bundle as part of a quality improvement project
designed to decrease postpartum hemorrhage rates.4 An inte-
gral part of this bundle includes system readiness with simu-
lation exercises and drills.
Our objective was to develop and implement a compre-
hensive, high fidelity, multidisciplinary obstetric simulation

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 Multidisciplinary In Situ Simulation-Based Training
exercise to train obstetric providers (staff physicians, midwives,
and residents), obstetric anesthesia providers (staff anesthesiol-
ogists, certified nurse anesthetists, residents, and student nurse
anesthetists), and labor and delivery nurses in obstetric emer-
gencies. In addition to assessing medical knowledge and tech-
nical skills, the simulation was designed to assess and reinforce
teamwork and communication skills, and to identify areas for
improvement within our health care system. One of the core
obstetric emergencies emphasized in this simulation exercise
was postpartum hemorrhage with activation of the obstetric
massive transfusion protocol. In addition, our goal was to
improve postpartum hemorrhage rates at our institution.
METHODS
This study was an approved clinical patient safety quality
improvement project conducted at a military tertiary care
medical center. As part of the Plan-Do-Study-Act quality
improvement cycle, we identified that our postpartum hem-
orrhage rate was elevated at 4%. In the planning phase, we
decided to follow our postpartum hemorrhage rate to moni-
tor outcomes after implementing the postpartum hemorrhage
bundle as well as specific projects and processes imple-
mented as part of the bundle. One of these projects was the
multidisciplinary simulation exercise, which was conducted
in October 2015. The goal of the exercise was to train 100%
of the obstetric providers and nurses while also training a
number of anesthesia providers that commonly work on
Labor and Delivery.
The simulation scenario took place on Labor and Deliv-
ery in one of the labor rooms. Simulation scenarios included
either an obstetric hypertensive emergency or shoulder dys-
tocia. This was followed by a postpartum hemorrhage, with
the requirement to activate the institutional obstetric mas-
sive transfusion protocol and obtain simulated blood prod-
ucts from the blood bank. Simulation participants were
also required to care for the baby following delivery to
assess neonatal resuscitation skills. Simulation scenarios
were developed for the Noelle obstetrics mannequin simu-
lator (Gaumard Scientific, Miami, FL) and the Newborn
HAL simulator (Gaumard Scientific).
All scenarios and learning objectives were developed and
reviewed by a multidisciplinary team of maternal fetal medi-
cine, obstetric, anesthesia, neonatology, transfusion services,
and nursing providers to ensure accuracy, plausibility, and
realism. Learning objectives encompassing medical knowl-
edge, patient care, and teamwork and communication were
established before the simulation exercise. Communication
and teamwork strategies from TeamSTEPPS5 were employed
as a conceptual framework. The tertiary health care system
has supported widespread education and implementation of
TeamSTEPPS as best practice for emergency patient manage-
ment. The primary objectives in both scenarios were recogniz-
ing and intervening appropriately to the obstetric emergency
(hypertension or shoulder dystocia) as well as identifying the
need for and activating the massive transfusion protocol and
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obtain blood products. A full blood bank tracer was conducted
during two of the scenarios to determine the time it took to
prepare and release a massive transfusion pack.
A total of 113 participants were trained over a 2-day
period, with 8 simulations/debriefs per day. Simulation
teams were created on the basis of typical staffing on call.
Teams consisted of a certified nurse midwife, resident in
obstetrics and gynecology, staff physician in obstetrics
and gynecology, 1 to 2 nurses, 1 to 2 corpsmen, and 1 to
2 anesthesia providers (combination of anesthesiologist,
anesthesia resident, nurse anesthetist, and student nurse
anesthetist). Each member of the simulation team partici-
pated within their authentic roles in an immersive real-life
setting on Labor and Delivery. Observers from key areas
(obstetrics, anesthesia, nursing, and pediatrics) evaluated par-
ticipants using standardized evaluation forms with medical
actions and teamwork/communication actions. Observers
received debriefing training before the exercise, using the
advocacy–inquiry debriefing theoretical framework.6 Dur-
ing the prebrief, all participants were advised the simula-
tion training was for quality improvement purposes and
learning, and that the basic assumption was that participants
were well trained, intelligent, and desired to do their best.
As one of the training goals was to critically evaluate our
obstetric massive transfusion protocol, a full blood bank
tracer was completed during two of the simulations. The
massive transfusion protocol was called overhead during
these simulations to test the overhead announcement system
and response. Blood bank team members simulated the prep-
aration of, and tracked the time for preparation and release
of a complete massive transfusion pack for a patient with
and without a type and screen on file.
Following the simulation, all teams debriefed in a stan-
dardized format. Participants and observers shared obser-
vations regarding patient care and medical knowledge,
teamwork and communication, and systems/process improve-
ment issues. Participants received didactic information
on key medical topics following the simulation. At the con-
clusion of the debriefing sessions, participants completed
voluntary, anonymous surveys regarding their simulation
experience, comfort in managing the clinical scenarios before
and after training, as well as additional feedback and sugges-
tions for the exercise. Provider comfort managing obstetric
emergencies was assessed using a 5-point Likert scale, with
1 being very uncomfortable and 5 being very comfortable.
A paired t test was used to assess differences in participant
responses before and after the simulation exercise. The num-
ber of postpartum hemorrhage cases was followed before
and after implementation of the simulation exercise to moni-
tor for trends. Statistical analysis was completed with
STATA software (StataCorp, College Station, Texas).
RESULTS
A total of 113 participants completed simulation training,
with 112 voluntary surveys returned for a response rate of
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 Multidisciplinary In Situ Simulation-Based Training
99.1%. The majority of participants were obstetric providers:
obstetric staff/residents (n = 34, 30%), midwives (n = 8,
7%), labor and delivery nurses (n = 33, 30%), corpsmen
(n = 14, 13%), and the remainder was anesthesia providers
(n = 23, 20%). (Fig. 1) The majority of participants (n = 103,
92%) had completed team training with Team STEPPS,
1 participant had completed a different team training, and
8 participants (7%) reported no prior team training.
Following simulation exercises, participants reported
higher comfort levels with managing both simulated obstet-
ric emergencies. For managing hypertensive emergencies,
there was a statistically significant increase in self-reported
post-training comfort levels, with a pretraining mean score
of 3.88, and a mean post-training score of 4.14 ( p = 0.01,
95% confidence interval [CI] = 0.06–0.47). Similarly, a sta-
tistically significant difference in the reported comfort in
responding to shoulder dystocia was reported, with mean
pretraining score of 3.66, and mean post-training score
of 4.29 (p = 0.001, 95% CI = 0.41–0.88). For postpartum
hemorrhage, which was assessed on both simulation days and
in both scenarios, the average pretraining score was 3.86, and
the average post-training score was 4.35, which was statisti-
cally significant ( p = 0.001, 95% CI = 0.36–0.63).
Subjective comments by participants revealed that virtu-
ally all participants felt the exercise was helpful, particularly
related to the evaluation of systems and communication/
teamwork components. Many participants realized areas for
improvement in teamwork, communication, and documenta-
tion during the exercise. Both participants and observers also
FIGURE 1. Simulation participant occupation (n = 112 participants).
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requested to complete similar training exercises more fre-
quently in the future. Overall, the simulation maintained a
high degree of realism, with many participants reporting that
they felt “stressed” during the hemorrhage, and many com-
ments conveyed that participants felt the simulation was
very realistic.
The time to prepare emergency release blood and a mas-
sive transfusion pack (6 units of packed red cells, 4 units
of fresh frozen plasma, 1 unit of platelets, and 1 unit of
cryoprecipitate) was simulated on 2 of the simulations.
One was simulated with a type and screen on file, whereas
the other was for a patient without a type and screen on
file (Table I). On the first day of the simulation, time to
prepare emergency release blood products (measured from
runner’s arrival at blood bank to blood being in the room
with the patient) was 6 minutes. On the second day, this
time decreased to 4 minutes. To prepare a massive transfu-
sion pack on the first day, with a type and screen on file, the
time was 22 minutes. On the second day, with no type and
screen on file, the time was 27 minutes.
The number of postpartum hemorrhage cases was mon-
itored for 6 months before initiating the postpartum hem-
orrhage simulation exercise, and 4 months following the
simulation exercise. We found a decreasing trend of post-
partum hemorrhage cases, which continued after initiating
the postpartum hemorrhage simulation exercise, as shown in
Figure 2.
DISCUSSION
In situ simulation involves simulations in the real-life patient
care setting. Because the simulation occurs in the patient
care setting, fidelity and learning are increased and organiza-
tional and systems challenges can be better identified.7 Our
results demonstrate that participants report higher comfort
levels with managing obstetric emergencies following in situ
simulation training. This finding supports previous research
that suggest adult learners retain more from hands on experi-
ences than from attending lectures.2
Postpartum hemorrhage remains a leading cause of mater-
nal morbidity and mortality in the United States. Compre-
hensive hemorrhage protocols and postpartum hemorrhage
bundles have been shown to improve patient safety,8 with
the use of massive transfusion protocols designed to rapidly
release transfusion packs containing packed red cells, clotting
factors, and platelets. Although a massive transfusion protocol
TABLE I. Time to Prepare Simulated Blood Products
Type No Type
and Screen and Screen
on File on File
Time to Prepare Emergency 6 Minutes 4 Minutes
Release Packed Red Cell Units
Time to Prepare Type-Specific 22 Minutes 27 Minutes
Massive Transfusion Pack
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 Multidisciplinary In Situ Simulation-Based Training
FIGURE 2. Linear trend of postpartum hemorrhage cases.
is a key step in obtaining necessary blood products, systems
processes and teamwork and communication must also func-
tion optimally to ensure rapid recognition of the need for
massive transfusion protocol and ultimately, timely receipt
of life saving blood products. During this simulation exer-
cise, the team was able to test the massive transfusion sys-
tem. We found that the time to ready emergency release
blood decreased on the second day. In addition, this simula-
tion identified that not all participants were able to locate the
blood bank, which could limit the pool of available runners
in a true emergency.
Several system-level areas for improvement were identi-
fied during the simulation exercise. During the exercise, it
was identified that tranexamic acid was not available in the
automated drug dispensing system on labor and delivery.
We also identified that additional colloid resuscitation fluids
(25% albumin and/or 5% Hextend, BioTime, Alameda,
California) were not available on the labor and delivery unit.
As a result of the drill, these issues were corrected before a
near miss or poor patient outcome. Another process gap
identified was that not all personnel were familiar with the
process to request and obtain blood products in an emer-
gency. This resulted in additional staff training of all pro-
viders and blood bank staff to ensure routine paperwork
was not required in an emergency. Although many of these
situations are not immediately apparent, practicing emer-
gency scenarios in a real-life setting were crucial to identify-
ing these gaps and resolving them in a timely fashion.
Overall, participants felt the simulation was beneficial and
realistic. A benefit to the authentic roles of individuals in the
in situ simulation environment is the ability to thoroughly ana-
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lyze and discuss team performance measures and communica-
tion on the basis of real-world experience among participants.
Focusing on communication is important, as communication
has been identified as a major root cause associated with
adverse events in health care.7 In addition, teamwork affects
overall team performance,8 and effective health care depends
on well-functioning multidisciplinary teams.9 During stan-
dardized debriefings, and using TeamSTEPPS as a concep-
tual framework, teams were able to discuss various teamwork
elements, including communication skills, leadership, situa-
tional awareness, and resource utilization, in addition to cog-
nitive skills and medical knowledge.
Simulation is particularly beneficial in obstetric emergen-
cies as these are high risk, low volume events, and require
rapid assessment, appropriate action, and well-functioning
teams and systems to ensure best patient outcomes. This
simulation exercise, which engaged providers of multiple
specialties, supported the hospital’s climate of team-based
learning, as participants were able to freely discuss both
cognitive and communication skills in a safe environment.
These principles of learning, continuous process improve-
ment and a preoccupation with systems failures support the
maintenance of a high reliability organizational structure
within our health care system.
National certification programs such as the Neonatal
Resuscitation Program, Advanced Life Support in Obstet-
rics, and Advanced Trauma Life Support focus on medical
knowledge and practical skills with written and “mega code”
examinations. However, such programs cannot assess real-
life teamwork interactions, or the ability of participants
to apply skills and knowledge in authentic environments.
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 Multidisciplinary In Situ Simulation-Based Training
In this regard, in situ simulation exercises including multiple
specialties are beneficial in skills maintenance and further
enhance communication and patient safety systems, and in
allowing participants to practice in a safe environment.
We also found a decreasing trend of postpartum hemor-
rhage cases, which continued after initiating the postpartum
hemorrhage simulation exercise. With the implementation
of the postpartum hemorrhage bundle at our institution, it is
impossible to fully ascribe the decreased postpartum hemor-
rhage cases at our institution to the simulation exercise
alone. However, with complex problems such as postpar-
tum hemorrhage, achieving improved quality and outcomes
requires a multidimensional solution.1 Our simulation exer-
cise is an integral part of our institutional effort directed
at decreasing postpartum hemorrhage, practicing skills, and
communication in a safe environment and identifying and
improving processes.
The limitations of this project include an inability to
directly correlate the effect of this simulation exercise as the
sole factor resulting in improved outcomes or communica-
tion. However, with the utilization of TeamSTEPPS as a
conceptual framework to guide best practice communication
and teamwork strategies, the authors and participants assert
this simulation exercise increased the sense of a shared men-
tal model. Furthermore, the use of in situ, interdisciplinary,
team-based simulation demonstrates the organization’s com-
mitment to learning and improving and is key in maintaining
a highly reliable organizational climate with a focus on
latent threats to patient safety.
In conclusion, we completed a comprehensive, high fidel-
ity, multidisciplinary obstetric simulation exercise, training
113 providers and nurses from multiple specialties in obstet-
ric emergencies. We tested our obstetric massive transfu-
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sion protocol in a realistic setting, and identified gaps and
improved several processes at our institution. Simulation
is a safe and effective way to practice and improve patient
safety and processes in a high-stakes environment, and the
project developers plan to continue these exercises in the
future to continue to learn and improve our response to
obstetric emergencies.
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