Failure modes and effects analysis to assess COVID-19 protocols in the management of obstetric emergencies

The Royal Free Hospital is one of four High Consequence Infectious Disease centres in England and as of the end of May 2020, seven women were confirmed COVID-19 peri-delivery. We developed a standard operating procedure (SOP) for suspected and confirmed COVID-19 women undergoing operative delivery. This was revised in response to our ongoing clinical experience and changes in guidance from medical and public health organisations. Following 10 weeks of clinical practice, we formally tested the SOP using point-of-care simulation to enable optimisation for a potential second surge. Our high-fidelity simulation of a COVID-19-positive parturient requiring an emergency caesarean was facilitated by the simulation team in our obstetric unit. It was designed to test the performance and safety of our SOP as well as staff performance. We used the Failure Modes and Effect Analysis tool (a systematic, prospective method of process mapping) to identify how a complex task might fail and assess the relative impact of different failures. The decision-to-delivery was 17 minutes, which we considered to be successful. However, a number of operational deficiencies were identified. The main failures related to lack of situational awareness, ill-fitting personal protective equipment and difficulties communicating between theatre and the neonatal teams located outside, posing serious potential risks to safe neonatal care. Subsequently, we have modified our SOP to include a communication check, implemented communication training for the neonatal team and organised further simulation training for theatre staff unfamiliar with COVID-19 considerations.