ORIGINAL ARTICLE Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance SS Lipman 1 , B Carvalho 1 , SE Cohen 1 , ML Druzin 2 and K Daniels 2 OBJECTIVE: We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean. STUDY DESIGN: Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children’s Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision. RESULT: The median (interquartile range) from time zero until incision was 9 min 27 s (8:55 to 10:27 min:s). CONCLUSION: In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery. Journal of Perinatology (2013) 33, 259–263; doi:10.1038/jp.2012.98; published online 2 August 2012 Keywords: delays in transport to the OR; emergency cesarean delivery; quality improvement; simulated obstetric crises; uterine rupture INTRODUCTION A variety of obstetric conditions lead to acute maternal–fetal decompensation and necessitate immediate emergency cesarean delivery (CD). The complexity of treating two patients (mother and unborn baby) simultaneously demands efficient multidisciplinary coordination during this process. As a result, the potential for task saturation, missed critical steps, delays and suboptimal team performance exists. Maternal complication rates are greater in emergency cesarean versus elective cesarean. 1 Multidisciplinary team practice for emergency CD is therefore both rational and prudent from a quality-improvement perspective. The clinical challenge is how best to utilize such drills for identification and improvement of care processes in the obstetric domain. The California Maternal Quality Care Collaborative and the United Kingdom’s Confidential Enquires into Maternal and Child Health have both recommended simulation training in the obstetric domain. 2,3 The Joint Commission and the American College of Obstetrics and Gynecology have gone a step further by specifically recommending drills in order to optimize emergency response. 4–6 Simulation training for rare but serious events in obstetrics has been associated with improved neonatal outcomes during shoulder dystocia 7 and improved performance during post-partum hemorrhage. 2 Obstetric simulation has been used to measure team performance, 8 delineate latent errors in the system, 9 elucidate recurrent provider management errors 10 and improve time to incision for prolapsed cord. 11 We conducted 14 uterine rupture drills on our labor and delivery unit (LDU) in order to measure team performance in initiating emergency cesarean in the setting of persistent fetal bradycardia. The primary outcome measure in the current investigation was the time required to move the patient from the labor and delivery room (LDR) to the operating room (OR) and make incision for emergency CD. Secondary outcomes were the subintervals measured (that is, time spent in actual transport and so on) and any barriers identified during the conduct of the drills. We hypothesized that the inherent time pressure in this scenario would provide a reasonable proxy for other obstetric emergencies and allow us to identify and improve barriers to rapid emergent transfer from the LDR to the OR. We chose to simulate uterine rupture at time of trial of labor after cesarean (TOLAC), specifically because the American College of Obstetrics and Gynecology has supported TOLAC as a means of decreasing current rates of CD, and recommends delivery units be logistically prepared (immediately available ORs and staff) to emergently provide CD in the event of a uterine rupture. 6 METHODS From September 2008 to April 2009, 14 teams participated in simulated, obstetric crisis drills on the LDU at Lucile Packard Children’s Hospital in Stanford, CA. These drills are a component of the quality-improvement process on the LDU and were therefore deemed exempt from oversight by the Institutional Review Board at Stanford University School of Medicine. Multidisciplinary team obstetric crisis drills are conducted regularly at Lucile Packard Children’s Hospital by two of the authors (KD and SL). This ongoing program is called OBSim, and the specific drills analyzed in this study were part of the OBSim program. 1 Division of Obstetric Anesthesia, Department of Anesthesiology, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Stanford, CA, USA and 2 Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA. Correspondence: Dr SS Lipman, Division of Obstetric Anesthesia, Department of Anesthesiology, Stanford University School of Medicine, Lucile Packard Children’s Hospital, MC5640, 300 Pasteur Drive, Stanford, CA 94305, USA. E-mail: steve.lipman@stanford.edu Portions of this data were presented at the annual meetings of the Society for Obstetric Anesthesia and Perinatology (May 2009, Washington, DC) and the American Society of Anesthesiologists (October 2009, New Orleans, L.A). Simulated in situ drills identified and led to remediation of institution-specific delays in initiating emergency cesarean delivery. Received 14 February 2012; revised 30 May 2012; accepted 4 June 2012; published online 2 August 2012 Journal of Perinatology (2013) 33, 259–263 & 2013 Nature America, Inc. All rights reserved 0743-8346/13 www.nature.com/jp