Proficiency-based progression training: an 'end to end' model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study

Karthikeyan Kallidaikurichi Srinivasan, Anthony Gallagher, Niall O'Brien, Vinod Sudir, Nick Barrett, Raymund O'Connor, Francesca Holt, Peter Lee, Brian O'Donnell, George Shorten, Karthikeyan Kallidaikurichi Srinivasan, Anthony Gallagher, Niall O'Brien, Vinod Sudir, Nick Barrett, Raymund O'Connor, Francesca Holt, Peter Lee, Brian O'Donnell, George Shorten

Abstract

Background: Training procedural skills using proficiency-based progression (PBP) methodology has consistently resulted in error reduction. We hypothesised that implementation of metric-based PBP training and a valid assessment tool would decrease the failure rate of epidural analgesia during labour when compared to standard simulation-based training.

Methods: Detailed, procedure-specific metrics for labour epidural catheter placement were developed based on carefully elicited expert input. Proficiency was defined using criteria derived from clinical performance of experienced practitioners. A PBP curriculum was developed to train medical personnel on these specific metrics and to eliminate errors in a simulation environment.Seventeen novice anaesthetic trainees were randomly allocated to undergo PBP training (Group P) or simulation only training (Group S). Following training, data from the first 10 labour epidurals performed by each participant were recorded. The primary outcome measure was epidural failure rate.

Results: A total of 74 metrics were developed and validated. The inter-rater reliability (IRR) of the derived assessment tool was 0.88. Of 17 trainees recruited, eight were randomly allocated to group S and six to group P (three trainees did not complete the study). Data from 140 clinical procedures were collected. The incidence of epidural failure was reduced by 54% with PBP training (28.7% in Group S vs 13.3% in Group P, absolute risk reduction 15.4% with 95% CI 2% to 28.8%, p=0.04).

Conclusion: Procedure-specific metrics developed for labour epidural catheter placement discriminated the performance of experts and novices with an IRR of 0.88. Proficiency-based progression training resulted in a lower incidence of epidural failure compared to simulation only training.

Trial registration number: NCT02179879. NCT02185079; Post-results.

Keywords: anaesthesia; medical education and training; simulation.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Outline of study phases 1 and 2.
Figure 2
Figure 2
Study phase 3: consort flow chart.

References

    1. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016;353:i2139 10.1136/bmj.i2139
    1. Institute of Medicine, Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, DC: The National Academies Press, 2000.
    1. Birkmeyer JD, Finks JF, O’Reilly A, et al. . Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013;369:1434–42. 10.1056/NEJMsa1300625
    1. Lorello GR, Cook DA, Johnson RL, et al. . Simulation-based training in anaesthesiology: a systematic review and meta-analysis. Br J Anaesth 2014;112:231–45. 10.1093/bja/aet414
    1. Bould MD, Crabtree NA, Naik VN. Assessment of procedural skills in anaesthesia. Br J Anaesth 2009;103:472–83. 10.1093/bja/aep241
    1. Ross AJ, Kodate N, Anderson JE, et al. . Review of simulation studies in anaesthesia journals, 2001-2010: mapping and content analysis. Br J Anaesth 2012;109:99–109. 10.1093/bja/aes184
    1. Stefanidis D, Sevdalis N, Paige J, et al. . Simulation in surgery: what’s needed next? Ann Surg 2015;261:846–53. 10.1097/SLA.0000000000000826
    1. Okuda Y, Bryson EO, DeMaria S, et al. . The utility of simulation in medical education: what is the evidence? Mt Sinai J Med 2009;76:330–43. 10.1002/msj.20127
    1. Zendejas B, Brydges R, Wang AT, et al. . Patient outcomes in simulation-based medical education: a systematic review. J Gen Intern Med 2013;28:1078–89. 10.1007/s11606-012-2264-5
    1. de Oliveira Filho GR. The construction of learning curves for basic skills in anesthetic procedures: an application for the cumulative sum method. Anesth Analg 2002;95:411–6.
    1. Friedman Z, Katznelson R, Devito I, et al. . Objective assessment of manual skills and proficiency in performing epidural anesthesia–video-assisted validation. Reg Anesth Pain Med 2006;31:304–10. 10.1097/00115550-200607000-00005
    1. Gallagher AG, Seymour NE, Jordan-Black JA, et al. . Prospective, randomized assessment of transfer of training (ToT) and transfer effectiveness ratio (TER) of virtual reality simulation training for laparoscopic skill acquisition. Ann Surg 2013;257:1025–31. 10.1097/SLA.0b013e318284f658
    1. Gallagher AG. Metric-based simulation training to proficiency in medical education:- what it is and how to do it. Ulster Med J 2012;81:107–13.
    1. Ahlberg G, Enochsson L, Gallagher AG, et al. . Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg 2007;193:797–804. 10.1016/j.amjsurg.2006.06.050
    1. Cates CU, Lönn L, Gallagher AG. Prospective, randomised and blinded comparison of proficiency-based progression full-physics virtual reality simulator training versus invasive vascular experience for learning carotid artery angiography by very experienced operators. BMJ Simulation and Technology Enhanced Learning 2016;2:1–5. 10.1136/bmjstel-2015-000090
    1. Angelo RL, Ryu RK, Pedowitz RA, et al. . A proficiency-based progression training curriculum coupled with a model simulator results in the acquisition of a superior arthroscopic bankart skill set. Arthroscopy 2015;31:1854–71. 10.1016/j.arthro.2015.07.001
    1. Pedowitz RA, Nicandri GT, Angelo RL, et al. . Objective assessment of knot-tying proficiency with the fundamentals of arthroscopic surgery training program workstation and knot tester. Arthroscopy 2015;31:1872–9. 10.1016/j.arthro.2015.06.021
    1. Van Sickle KR, Ritter EM, Baghai M, et al. . Prospective, randomized, double-blind trial of curriculum-based training for intracorporeal suturing and knot tying. J Am Coll Surg 2008;207:560–8. 10.1016/j.jamcollsurg.2008.05.007
    1. Seymour NE, Gallagher AG, Roman SA, et al. . Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002;236:458–63. 10.1097/01.SLA.0000028969.51489.B4
    1. Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia "learning curve". What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 1996;21:182–90.
    1. Gallagher AG, Smith CD, Bowers SP, et al. . Psychomotor skills assessment in practicing surgeons experienced in performing advanced laparoscopic procedures. J Am Coll Surg 2003;197:479–88. 10.1016/S1072-7515(03)00535-0
    1. Tansley P, Kakar S, Withey S, et al. . Visuospatial and technical ability in the selection and assessment of higher surgical trainees in the London deanery. Ann R Coll Surg Engl 2007;89:591–5. 10.1308/003588407X187702
    1. Thangamuthu A, Russell IF, Purva M. Epidural failure rate using a standardised definition. Int J Obstet Anesth 2013;22:310–5. 10.1016/j.ijoa.2013.04.013
    1. Gallagher AG, Ritter EM, Satava RM. Fundamental principles of validation, and reliability: rigorous science for the assessment of surgical education and training. Surg Endosc 2003;17:1525–9. 10.1007/s00464-003-0035-4
    1. Naik VN, Perlas A, Chandra DB, et al. . An assessment tool for brachial plexus regional anesthesia performance: establishing construct validity and reliability. Reg Anesth Pain Med 2007;32:41–5. 10.1016/j.rapm.2006.10.009
    1. Chin KJ, Tse C, Chan V, et al. . Hand motion analysis using the imperial college surgical assessment device: validation of a novel and objective performance measure in ultrasound-guided peripheral nerve blockade. Reg Anesth Pain Med 2011;36:213–9. 10.1097/AAP.0b013e31820d4305
    1. Burckett-St Laurent DA, Niazi AU, Cunningham MS, et al. . A valid and reliable assessment tool for remote simulation-based ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2014;39:496–501. 10.1097/AAP.0000000000000165
    1. Gallagher AG, O’Sullivan GC, Leonard G, et al. . Objective structured assessment of technical skills and checklist scales reliability compared for high stakes assessments. ANZ J Surg 2014;84 10.1111/j.1445-2197.2012.06236.x
    1. Chuan A, Graham PL, Wong DM, et al. . Design and validation of the regional anaesthesia procedural skills assessment tool. Anaesthesia 2015;70:1401–11. 10.1111/anae.13266
    1. Roberts RB. The occurrence of unblocked segments during continuous lumbar epidural analgesia for pain relief in labour. Br J Anaesth 1972;44:628 10.1093/bja/44.6.628-a
    1. Michael S, Richmond MN, Birks RJ. A comparison between open-end (single hole) and closed-end (three lateral holes) epidural catheters. Complications and quality of sensory blockade. Anaesthesia 1989;44:578–80.
    1. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004;13:227–33. 10.1016/j.ijoa.2004.04.008
    1. Bishton IM, Martin PH, Vernon JM, et al. . Factors influencing epidural catheter migration. Anaesthesia 1992;47:610–2. 10.1111/j.1365-2044.1992.tb02337.x

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi