I led this project from idea to validation over a year as part of my bioengineering design capstone course. DAPHNE, or Dynamic & Accessible Postpartum Hemmorage Novice Educator, aims to help novice labor & delivery nurses better recognize and initially manage postpartum hemorrhage via simulation-based training.
DAPHNE is my bioengineering senior design course project. In September, our team spoke with doctors, nurses, physical therapists, and clinical professors to identify nearly 50 unmet clinical needs. Based on a weighted decision matrix and further conversations with users, stakeholders, and experts, our team choose to work on improving the recognition and initial management of postpartum hemorrhage.
This course enabled me to learn...
I helped guide our human-centered, data-driven design process and implement some best practices of high-performance teams. I built low-resolution user experience prototypes with paper & foamcore, rapid prototypes with laser cutting, and functional prototypes using microcontrollers and motors. We continuously tested all of these with users.
My specific contributions include,
People often describe the birth of their child as one of the best moments in their lives. Unfortunately, this moment is destroyed for the 125,000 women in the US affected each year by postpartum hemorrhage, which is excessive maternal bleeding within the first 24 hours after birth.
Postpartum hemorrhage is a leading cause of maternal mortality in our country.
Despite this, approximately 74% of these deaths are preventable. Women die from postpartum hemorrhage because they fail to receive early initiation of effective intervention.
Women die from postpartum hemorrhage because they don’t receive early initiation of effective interventions.
Novice labor and delivery nurses are often delayed in recognizing the signs of postpartum hemorrhage and implementing initial treatment.
One approach often used to help prepare clinicians is simulation-based training. Based on initial conversations with the Winter Institute for Simulation Education and Research (WISER) and other medical simulation centers, we found that existing labor and delivery simulators are insufficient to fully train nurses to properly manage postpartum hemorrhage.
DAPHNE is composed of two main systems:
a dynamic mock uterus system and a mock blood loss system.
The dynamic uterus can transition from soft to firm upon abdominal massage. The quantifiable blood loss system simulates blood loss at a physiologically accurate and controllable rate, which nurses can quantify during the scenario. These components enable DAPHNE to provide a real-time configuration of blood flow rate, blood colors, and total blood amount lost during a simulation scenario. Our team is currently designing both clinical scenario simulation protocol as well as a simulator control interface in collaboration with WISER.
When a nurse initiates a proper fundal massage, the simulation operator controls the dynamic uterus inside DAPHNE to contract via deflation of a water-filled pouch connected to a solenoid-operated valve. Upon deflation, the nurse can feel the anatomically accurate firmer and smaller 3D printed uterus.
Iterative development of an anatomically-accurate 3D-printed uterus. Each iteration was tested by an experienced labor & delivery nurse. The final orange model was selected and strapped into a fixture with the softer water bag on top.
A simulation operator modulates the mock blood flow based on the scenario and in response to fundal massage. Mock blood flows with a peristaltic pump up to 100 mL/min via microcontroller adjustment.
We have already tested DAPHNE with one experienced labor & delivery nurse, three senior nursing students, and an Assistant Professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at UPMC Magee-Womens Hospital. Our team also won 1st Place in Bioengineering at the Fall 2019 Design Expo.
VER-1: Mock Blood Flow System Controlled Flow
This test measured the flow rate of liquid exiting the system to ensure it is flowing at a physiologically accurate rate for postpartum hemorrhage. An average of 108.59 mL/min was reported over the 10 min testing period, which confirmed that the peristaltic pumps are sufficient to pump at a physiologically accurate rate for the duration the participant will be interacting with the simulation.
VER-2: Mock Uterus System Water Evacuation
This test will measured whether water could exit the water bladder at a rate simulating a physiologically accurate contracting uterus during a fundal massage. The results showed that the average water evacuation of the uterus due to 50 lbs of simulated fundal massage pressure over 30 seconds was 1097.4 mL.
VER-3: Mock Uterus System Compressive Force
This test measured the ability of the system to withstand a continuous compressive downward force while simulating a “boggy” fundus (inflated water reservoir) and a “firm” fundus (deflated water reservoir). The results showed that the mock uterus system is robust enough to withstand a compression of a 850 N load.
VER-4: Mock Uterus System Cycle Testing
This test measured the ability of the system to withstand a continuous compressive downward force while simulating a “boggy” fundus (inflated water reservoir) and a “firm” fundus (deflated water reservoir). The results show that the mock uterus system is robust enough to withstand repeated 45 second compressions of a 530 N load.
VAL-1: Performance Validation Test
This test would’ve evaluated whether the simulation trainer meets the learning needs of participant novice labor and delivery nurses with respect to postpartum hemorrhage events using a before and after design. The hypothesis of the study is whether deliberate practice of an obstetric postpartum hemorrhage scenario incorporating DAPHNE (realistic fundus and blood loss system) improves participant performance in postpartum hemorrhage recognition and initial management.
Due to the extenuating circumstances during Spring 2020 of the coronavirus pandemic, VAL-1 was unable to be executed as planned. WISER IRB approval was obtained and six School of Nursing participants with L&D experience were recruited and scheduled to execute
VAL-1 protocol the weeks of 3/16 and 3/23. However, to maintain proper social distancing guidelines emphasized for Allegheny county the study was canceled.
VAL-2: Anatomical Fidelity Validation Test
This test evaluated whether the mock uterus component enables the simulation of a fundal massage with appropriate anatomical fidelity. The goal was to determine the similarity of the mock dynamic uterus to real life experience.
Due to the extenuating circumstances during Spring 2020 of the coronavirus pandemic, VAL-2 was unable to be executed as planned. Only one of the subject matter experts was able to evaluate the fidelity of the device the week of 3/2. However, to maintain proper social distancing guidelines emphasized for Allegheny County the study was canceled.
VAL-3: Video Validation Test
This test collected feedback from simulation operation specialist and novice nursing students (at least one rotation of labor and delivery unit experience) on the importance and effectiveness of the device components (mock blood loss system, dynamic uterus system, and physiologically accurate skin) for a postpartum hemorrhage simulation training. The goal was to collect feedback on the functionality and usability of the device. In terms of acceptability criteria, participants surveyed should on average indicate that the device is at minimum satisfactory representation, defined as an average of 3.5 out of 5 or greater on the survey questions. The scoring of survey questions is as follows: 1-strongly disagree, 2-disagree, 3-neutral, 4-agree, 5-strongly agree.
The Simulation Specialist survey received six responses from institutions including SimTiki Simulation Center in Honolulu, Hawaii, Sidra Medicine in Doha, Qatar, Penn State Health Milton S. Hershey Medical Center in State College, Pennsylvania, The Ohio State University Wexner Medical Center in Columbus, Ohio, Mark Richardson Interprofessional Simulation Center in Portland, Oregon, and the Jackson Memorial Hospital Center for Patient Safety in Miami, Florida. The Nursing Student survey received seven responses from either junior or senior nursing students at the University of Pittsburgh School of Nursing. The components of the DAPHNE system were surveyed by simulation specialists to have a mean importance of 4.22 and an overall mean effectiveness of 3.89, and the components of the DAPHNE system were surveyed by nursing students to have an overall mean importance of 3.78 and a mean effectiveness of 3.86.
Future Directions
Team DAPHNE hopes to improve our current design and continue the efforts of VAL-1 with the addition of new nursing and engineering team members in the Simulation & Medical Technology R&D Center under the supervision of Dr. Joe Samosky. We hope that DAPHNE will one day be available to simulation centers and nursing schools around the world!
