Multidisciplinary Programed Learning Simulation to Improve Visual Blood Loss Estimation for Obstetric Trauma Scenarios

We designed and implemented a Programmed Learning Simulation (PLS) exercise depicting obstetric scenarios of hemorrhage to train anesthesiologists, ancillary staff, and surgeons to accurately estimate blood loss visually. We then measured the efficacy of this exercise in a clinical setting.

We conducted a prospective study to assess the effect of implementing a PLS exercise on quantification of blood loss in an operative setting. The PLS exercise consisted of 13 simulation stations of varying quantities of simulated blood loss paired with standardized objects of known volume. Eighty-eight individuals participated including attending physicians, residents, medical students, and ancillary staff participated in this study. The PLS was part of regularly scheduled continuing medical education activities; thus, the sampling used was non-randomized convenience method. The percent error was calculated for each of the 13 stations. A subgroup analysis was performed to assess the effect of the years of experience, size of hemorrhage, and occupation on accuracy. Univariate analyses for continuous variables were compared using a one-way ANOVA test. For the comparison of the three groups (years of experience and size of hemorrhage), a p-value of <0.02 was considered statistically significant and for 5-way comparison (professional grouping) a p <0.01 was considered significant after application of the Bonferroni correction (α=0.05). (Part A). To determine the effect of PLS in a clinical setting, the percent error of blood loss estimation for cesarean deliveries during the two-month period after the PLS exercise was compared to the two-month period immediately prior to using the student's t-test with p<0.05 as significant (Part B). Statistical analysis was performed using International Business Machine, Statistical Package for the Social Sciences, Version 26.0 (IBM SPSS).

During Part A, the baseline performance of the participants was evaluated during the PLS activity. The PLS data showed no significant difference in absolute value of mean percent error estimation (standard deviation) across professions: student 63.61% (69.74), ob/gyn 56.91% (47.72), ancillary 62.15% (77.90), general/trauma surgeon 66.70% (65.06), anesthesia 61.51% (63.12). (p = 0.681), or levels of experience 0-5: 62.21% (60.06), 6-10 years: 56.22% (52.66), greater than 10 years: 61.89% (71.89) (p = 0.831). However, mean percent error of estimation was higher when participants estimated smaller samples 77.7% (104.73) compared to either medium 56.8% (49.06) or large 57.9% (46.19) samples (p<0.001). For Part B, 179 cesarean deliveries occurred during the pre-intervention period and 193 occurred during the post-intervention period. Mean error in provider estimation of blood loss significantly improved from 47% (68.51) pre-intervention to 31% (32.70) post-intervention (p=0.009).

We believe our described PLS activity was effective in teaching techniques for visual blood loss estimation. This was reflected by improved competency in a clinical setting, demonstrated by more accurate visually estimated blood loss during the period immediately following simulation activity compared to a prior time frame. Further research is needed to assess the impact of simulation activities on patient outcomes, such as utilization of blood products and patient morbidity.