GME Patient Safety Quality and Innovation Symposium

Background: Induction of fetal demise is an advanced procedural skill in Obstetrics and Gynecology (OBGYN) that expands patient access to later-gestation abortion care while mitigating risk of unintended live periviable births. Additionally, the literature shows that many patients prefer induction of fetal demise prior to termination of pregnancy when presented with the option. Despite this, ultrasound-guided injection for fetal asystole is an under-taught skill in abortion training programs, most OBGYN residencies, and many Complex Family Planning (CFP) fellowships. A simulation for this procedure could be a steppingstone for clinicians to learn this skill in a low-risk setting before incorporating it into clinical practice.

Description: This project aims to increase the average clinician comfort and confidence score when performing ultrasound-guided needle procedures such as induction of fetal asystole following standardized simulation training among the participating faculty clinicians. Clinician participants included attendings and fellows from the CFP and the Maternal-Fetal Medicine (MFM) divisions. Study team members used the Rubin Model to conduct standardized simulation of injection for fetal asystole (Figure 1). The Rubin Model is a high-fidelity system consisting of three nested ballons (one which represents the fetal heart, one which represents the fetal body, and one which represents the amniotic sac) specifically designed to teach ultrasound-guided intra-amniotic, intrafetal, and intracardiac injections. Other educational materials developed for this project include a division-wide protocol to facilitate introduction of this skill into clinical practice and a patient-facing Frequently Asked Questions document to address common questions and concerns that patients may have when being counseled on the risk/benefits/alternatives of undergoing injection for fetal asystole. These documents were reviewed with participants prior to procedural simulation along with relevant evidence on diVerent pharmacologic agent options and diVerent ultrasound techniques (Figure 2). Clinician comfort and confidence was assessed using pre-simulation and post-simulation 10-question 5-point Likert scale surveys. Questions covered areas including general confidence, technique and equipment, patient safety and communication, and overall preparedness.

Lessons learned or expected outcomes: Seven faculty clinicians participated in the standardized simulation of injection for fetal asystole and took the pre- and post-surveys. With success defined an average post-training score of 4.0 or higher across all ten questions OR an absolute increase of 1.0 points from the pre-training average score, this simulation had a 72% success rate. Average post-training scores increased by 36% (or 1.2 points out of 5) from average pre-training scores (Figure 3).

Recommendations/next steps: UCSD CFP faculty are now trained for and will begin to oVer injection for fetal asystole to appropriate patient candidates. This simulation will be conducted for CFP and MFM fellows on a yearly basis. Ultimately, the goal is to help clinicians expand their skillsets to include this procedure, thereby improving patient access to second-trimester abortion.