Every obstetrical department works to provide safe outcomes for mothers and babies. Many critical access, rural hospitals provide low volume, low risk obstetrical care.  However, they must be prepared to deal with any catastrophic event associated with increased maternal or neonatal morbidity or mortality.  And yet, they are challenged to find the best way to implement evidence based care when these events happen so infrequently.  Large urban facilities have resources that may include clinical nurse specialists, nurse educators, nurse practitioners and access to large ancillary services.  But how does a facility, hundreds of miles from a large tertiary facility, develop competency in their staff members?

Proposed change:  

Improving patient outcomes requires use of evidenced based care, applying systems thinking and increased training.  This rural facility put together evidenced based protocols for how to facilitate emergent care for placenta abruption, extreme prematurity and hemorrhage – all low frequency occurrences that have been experienced with poor outcomes.  The proposed changes included roll specific functions and responses, initiating the chain of communication, redesigning their unit and regular drills.

Implementation, outcomes and evaluation:  

The first step included a root cause analysis of low frequency, high risk events.  From this, a protocol was developed, adapting to the unique resources and needs of this small facility.  The next step was to test the protocol.  Simulation, using a simulation mannequin, was utilized and every clinical staff member who provided obstetric care participated, including physicians.  Revisions were made to the protocol and retested.  

In addition, clinical decision support was added to the electronic medical record (EMR) to prompt the clinician to the appropriate actions and orders in a given situation.  The EMR also prompts for appropriate documentation to ensure a complete record. 

Implications for nursing practice:  

Overall, staff readiness was improved by utilizing simulation to define the process, educate, and assess competency.   The use of simulation for ongoing team evaluation will continue to reinforce these skills so if the unthinkable happens, this nursing staff, and medical staff, will be prepared to ensure the most optimal outcome.

Keywords: simulation, critical access, rural facility, low frequency/high risk events