Effect of hands-on interprofessional simulation training for local emergencies in Scotland

the THISTLE stepped-wedge design randomised controlled trial

Erik Lenguerrand (Lead / Corresponding author), Cathy Winter, Dimitrios Siassakos, Graeme MacLennan, Karen Innes, Pauline Lynch, Alan Cameron, Joanna Crofts, Alison McDonald, Kirsty McCormack, Mark Forrest, John Norrie, Siladitya Bhattacharya, Tim Draycott

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    Abstract

    OBJECTIVE: To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins).

    DESIGN: Stepped-wedge cluster randomised controlled trial.

    SETTING: Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016.

    INTERVENTION: The PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff.

    MAIN OUTCOME MEASURES: The primary outcome was the proportion of term babies with Apgar<75mins.

    RESULTS: 87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the 'intention-to-treat' analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate.

    CONCLUSIONS: PROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively.

    TRIAL REGISTRATION NUMBER: ISRCTN11640515.

    Original languageEnglish
    Number of pages13
    JournalBMJ Quality & Safety
    Early online date13 Jul 2019
    DOIs
    Publication statusE-pub ahead of print - 13 Jul 2019

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    Apgar Score
    Scotland
    Emergencies
    Randomized Controlled Trials
    Parturition
    Intention to Treat Analysis
    Obstetrics
    Health Services
    Research
    Simulation Training

    Cite this

    Lenguerrand, Erik ; Winter, Cathy ; Siassakos, Dimitrios ; MacLennan, Graeme ; Innes, Karen ; Lynch, Pauline ; Cameron, Alan ; Crofts, Joanna ; McDonald, Alison ; McCormack, Kirsty ; Forrest, Mark ; Norrie, John ; Bhattacharya, Siladitya ; Draycott, Tim. / Effect of hands-on interprofessional simulation training for local emergencies in Scotland : the THISTLE stepped-wedge design randomised controlled trial. In: BMJ Quality & Safety. 2019.
    @article{90d8ba31ec5644af8ce3549359667d60,
    title = "Effect of hands-on interprofessional simulation training for local emergencies in Scotland: the THISTLE stepped-wedge design randomised controlled trial",
    abstract = "OBJECTIVE: To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins).DESIGN: Stepped-wedge cluster randomised controlled trial.SETTING: Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016.INTERVENTION: The PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff.MAIN OUTCOME MEASURES: The primary outcome was the proportion of term babies with Apgar<75mins.RESULTS: 87 204 eligible births (99.2{\%} with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49{\%}, increasing from 1.32{\%} preintervention to 1.59{\%} postintervention. Once adjusted for a secular time trend, the 'intention-to-treat' analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95{\%}CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate.CONCLUSIONS: PROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively.TRIAL REGISTRATION NUMBER: ISRCTN11640515.",
    author = "Erik Lenguerrand and Cathy Winter and Dimitrios Siassakos and Graeme MacLennan and Karen Innes and Pauline Lynch and Alan Cameron and Joanna Crofts and Alison McDonald and Kirsty McCormack and Mark Forrest and John Norrie and Siladitya Bhattacharya and Tim Draycott",
    note = "The authors thank the CSO for funding the THISTLE study and the staff of the Scottish maternity units for their participation and continued support with the THISTLE Study {\circledC} Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.",
    year = "2019",
    month = "7",
    day = "13",
    doi = "10.1136/bmjqs-2018-008625",
    language = "English",
    journal = "BMJ Quality & Safety",
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    publisher = "BMJ Publishing Group",

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    Lenguerrand, E, Winter, C, Siassakos, D, MacLennan, G, Innes, K, Lynch, P, Cameron, A, Crofts, J, McDonald, A, McCormack, K, Forrest, M, Norrie, J, Bhattacharya, S & Draycott, T 2019, 'Effect of hands-on interprofessional simulation training for local emergencies in Scotland: the THISTLE stepped-wedge design randomised controlled trial', BMJ Quality & Safety. https://doi.org/10.1136/bmjqs-2018-008625

    Effect of hands-on interprofessional simulation training for local emergencies in Scotland : the THISTLE stepped-wedge design randomised controlled trial. / Lenguerrand, Erik (Lead / Corresponding author); Winter, Cathy; Siassakos, Dimitrios; MacLennan, Graeme; Innes, Karen; Lynch, Pauline; Cameron, Alan; Crofts, Joanna; McDonald, Alison; McCormack, Kirsty; Forrest, Mark; Norrie, John; Bhattacharya, Siladitya; Draycott, Tim.

    In: BMJ Quality & Safety, 13.07.2019.

    Research output: Contribution to journalArticle

    TY - JOUR

    T1 - Effect of hands-on interprofessional simulation training for local emergencies in Scotland

    T2 - the THISTLE stepped-wedge design randomised controlled trial

    AU - Lenguerrand, Erik

    AU - Winter, Cathy

    AU - Siassakos, Dimitrios

    AU - MacLennan, Graeme

    AU - Innes, Karen

    AU - Lynch, Pauline

    AU - Cameron, Alan

    AU - Crofts, Joanna

    AU - McDonald, Alison

    AU - McCormack, Kirsty

    AU - Forrest, Mark

    AU - Norrie, John

    AU - Bhattacharya, Siladitya

    AU - Draycott, Tim

    N1 - The authors thank the CSO for funding the THISTLE study and the staff of the Scottish maternity units for their participation and continued support with the THISTLE Study © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

    PY - 2019/7/13

    Y1 - 2019/7/13

    N2 - OBJECTIVE: To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins).DESIGN: Stepped-wedge cluster randomised controlled trial.SETTING: Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016.INTERVENTION: The PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff.MAIN OUTCOME MEASURES: The primary outcome was the proportion of term babies with Apgar<75mins.RESULTS: 87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the 'intention-to-treat' analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate.CONCLUSIONS: PROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively.TRIAL REGISTRATION NUMBER: ISRCTN11640515.

    AB - OBJECTIVE: To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins).DESIGN: Stepped-wedge cluster randomised controlled trial.SETTING: Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016.INTERVENTION: The PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff.MAIN OUTCOME MEASURES: The primary outcome was the proportion of term babies with Apgar<75mins.RESULTS: 87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the 'intention-to-treat' analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate.CONCLUSIONS: PROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively.TRIAL REGISTRATION NUMBER: ISRCTN11640515.

    U2 - 10.1136/bmjqs-2018-008625

    DO - 10.1136/bmjqs-2018-008625

    M3 - Article

    JO - BMJ Quality & Safety

    JF - BMJ Quality & Safety

    SN - 2044-5415

    ER -