Proficiency based progression training for epidural catheter placement for labour analgesia
Medical errors account for as many as 250,000 deaths in the US every year. A significant proportion of such errors (44% by one estimate) are related to procedural skills. Although simulation based training methods have been developed to address the deficiencies in training, there is limited evidence to show it reduces procedural errors or that it improves patient outcomes. By employing a tool known as 鈥淧ro颅fi颅ciency-based pro颅gres颅sion (PBP)鈥� we were able to show improved pa颅tient outcomes. Pre颅vi颅ous in颅ves颅ti颅ga颅tions of med颅i颅cal train颅ing using this tool have fo颅cused on the per颅for颅mance of the doc颅tor rather than a mean颅ing颅ful pa颅tient out颅come.
This study titled 鈥溾�� was published in the Bri颅tish Med颅i颅cal Jour颅nal Open (BMJ Open). In de颅vel颅op颅ing the train颅ing tech颅nique, we se颅lected a pro颅ce颅dure鈥攊n this case epidu颅ral鈥攁nd bro颅ken it down into a se颅ries of 鈥渕i颅cro颅tasks鈥漮r 鈥淢etrics鈥�. We ob颅served both ex颅perts and novices in epidu颅ral catheter in颅ser颅tion per颅form颅ing each mi颅cro颅task with the fo颅cus on what should or should not hap颅pen, and at the end of an eight-month process, a se颅ries of met颅rics emerged.
Anaes颅the颅sia trainees had to suc颅cess颅fully demon颅strate their com颅pe颅tence in each met颅ric 鈥� 74 in all 鈥� be颅fore pro颅gress颅ing to the next step or mi颅cro颅task. For in颅stance, one met颅ric re颅quired the doc颅tor to cover an A4-sized area of the pa颅tient鈥檚 back when paint颅ing on asep颅tic so颅lu颅tion. In the event of not meet颅ing this re颅quire颅ment, they were deemed not to have com颅pleted the met颅ric. Train颅ing could not progress un颅til the met颅ric was met.
This train颅ing tool that could mea颅sure the trainee鈥檚 ef颅fec颅tive颅ness along each tiny step of a pro颅ce颅dure proved highly ef颅fec颅tive in our trial. In fact pa颅tients of trainees who had trained us颅ing this tool re颅sponded much more pos颅i颅tively to epidu颅ral com颅pared to doc颅tors who un颅der颅went stan颅dard sim颅u颅la颅tion based train颅ing. The fail颅ure rate for those with stan颅dard train颅ing was 24% com颅pared to 12% who used the PBP effectively halving the failure rate (figure 1).
One hun颅dred and 40 women took part in the clin颅i颅cal trial at CUMH be颅tween Jan颅uary 2015 and Septem颅ber 2016. To be el颅i颅gi颅ble, it had to be es颅tab颅lished that they were in labour and had cho颅sen to have an epidu颅ral. If the midwife deemed the pa颅tient to be com颅fort颅able within 60 min颅utes or less of hav颅ing the epidu颅ral, the pro颅ce颅dure was deemed a suc颅cess.
The lim颅i颅ta颅tions of the trial were the small sam颅ple size and the fact that it took place in just one hospi颅tal. How颅ever this study assumes importance in that it is the first of its kind where a training modality has shown to improve patient outcomes in a meaningful manner.
