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 Wat bevalt beter


TOSTI study



Training Obstetrische Spoed Teams Interventie (TOSTI) 


Reducing errors in health care: cost-effectiveness of multidisciplinary team training in obstetric emergencies.


Go to the TOSTI website


There are many avoidable deaths in hospitals because the care team is not well attuned. Training in emergency situations is generally followed on an individual basis. In practice, however, hospital patients are treated by a team composed of various disciplines. To prevent communication errors, it is important to focus the training on the team as a whole, rather than on the individual. Team training appears to be important in contributing toward preventing these errors. Obstetrics lends itself to multidisciplinary team training. It is a field in which nurses, midwives, obstetricians and paediatricians work together and where decisions must be made and actions must be carried out under extreme time pressure.

It is attractive to believe that multidisciplinary team training will reduce the number of errors in obstetrics. The other side of the medal is that many hospitals are buying expensive patient simulators without proper evaluation of the training method. In the Netherlands many hospitals have 1,000 or less annual deliveries. In our small country it might therefore be more cost-effective to train obstetric teams in medical simulation centres with well trained personnel, high fidelity patient simulators, and well defined training programmes.


The aim of the present study is to evaluate the cost-effectiveness of multidisciplinary team training in a medical simulation centre in the Netherlands to reduce the number of medical errors in obstetric emergency situations.

Study design
Multicentre randomised study with the centre as unit of analysis. Obstetric departments will be randomly assigned to receive multidisciplinary team training in a medical simulation centre or to a control arm.

Study population

Teaching and non-teaching hospitals in the Netherlands. We excluded hospitals which already have frequently multidisciplinary team training for its care workers.

The intervention group will have multidisciplinary team training in a medical simulation centre. These team trainings are given by specially trained instructors and facilitators (gynaecologists, anaesthesiologists, emergency care doctors, midwives, educationalists, medical engineers and psychologists). All instructors and facilitators are trained in crew resource management. The control group will not have multidisciplinary team training.

Outcome measures

Primary outcome is the number of obstetric complications throughout the first year after the intervention. Obstetric complications will be defined as the number of neonates with perinatal asphyxia (Apgar 5-minutes <6 and/or arterial umbilical pH < 7.05, hypoxic ischemic encephalopathy (H.I.E.), number of newborns with damage caused by shoulder dystocia (lesion of brachial plexus, clavicle fracture), number of women with eclampsia, number of women with severe post partum haemorrhage (blood transfusion >4 packed cells), hysterectomy, embolisation), number of women with amniotic fluid embolism. These complications will be obtained from the regular obstetric recordings (with exception of damage due to shoulder dystocia and severe postpartum haemorrhage, these data will be registered separately).

Before the start of the project indicators will be developed to evaluate patient safety, teamwork and human factors. These indicators will be registered in a subgroup of the participating hospitals.

Power/data analysis
The analysis will be by intention-to-treat and stratified for teaching or non-teaching hospital.  To show a reduction in perinatal asphyxia of 40% (from 1% to 0.6%) two groups of more than 8,000 patients are necessary.

Economic evaluation
The trial results will be incorporated in a cost-effectiveness analysis to compare the costs and effects of multidisciplinary team training in a medical simulation centre (experimental strategy) versus no such training (reference strategy).

Time schedule
Total study time 36 months. 9 months to develop indicators to evaluate patient safety, teamwork and human factors and schedule team trainings.  6 months team training in medical simulation centre. 12 months follow-up. 9 months analysis and report.

Prof. dr. S.G. Oei, gynaecologist, Maxima Medical Centre Eindhoven-Veldhoven

Prof. dr. B.W. Mol, gynaecologist, Academic Medical Centre Amsterdam

Health Technology Assessment & Methodology
Prof. dr. B.W. Mol, gynaecologist, Academic Medical Centre Amsterdam

ZonMw –



Drs. J. van de Ven, resident Obstetrics and Gynaecology, Máxima Medical Centre Eindhoven-Veldhoven

E-mail: TOSTI@studies-obsgyn.nl


Máxima Medical Centre

De Run 4600

P.O.Box 7777

5500 MB Veldhoven NL

The Netherlands

T: +31 (0)40 8888385

F: +31 (0)40 8888387