Proficiency-based progression training: implementing a novel approach to training for epidural analgesia in labour

BACKGROUND

Epidural insertion is a challenging anaesthetic procedural skill to learn and may require up to 75 attempts to achieve competency. Proficiency-based progression (PbP) training based on unambiguously defined metrics was associated with a 53% reduction in epidural failure rate. The aim of this observational study was to examine the feasibility of implementation of innovative PbP training for labour epidural insertion performed by novices in a busy tertiary hospital.

METHODS

All trainees who were scheduled to commence their obstetric anaesthesia training were invited to participate. Novices undertook intensive PbP training with one-to-one supervision by an anaesthetist trained in PbP. Trainees proceeded to the clinical phase only after attaining the pre-defined proficiency benchmark. All subsequent attempts at labour epidural catheter placement were evaluated.

RESULTS

All 12 novice trainees who were scheduled for their initial exposure to obstetric anaesthesia completed PbP training in epidural catheter insertion successfully. The average duration of the training courses was 70 (SD 11) min. Trainee characteristics were broadly similar. They performed a total of 180 labour epidural catheter placements with an overall epidural failure rate of 12.2% (22/180). The proportion of supervisor takeover was 6% (11/179). The incidence of complications was 4% (8/180) and difficulty in epidural catheter insertion due to patient factors was 16% (29/180). Patient satisfaction rates were 80% (satisfied or very satisfied), with 20% unsatisfied with their experience of epidural insertion.

CONCLUSION

In our experience, PbP training in epidural placement is feasible within existing departmental resources in a busy tertiary teaching hospital setting.

[Evaluation of nephropathies in children with rheumatoid arthritis and prolonged therapy with salicylates]

The study included 18 school-age and adolescent patients with juvenile rheumatoid arthritis who had consumed from 351 to 6393 gm. (average 2813 gm.) as total dose for the control of their disease. All of them underwent a complete physical examination, general laboratory tests and as specific tests of renal function; urinalysis, urine culture, endogenous creatinine clearance, Addis count (red and white cells), sodium and potassium urinary excretion, urinary acidity capacity, administration of ammonium chloride and capacity of urinary concentration following water restriction. Normal results in practically all parameters led to conclude that a clear evidence of nephropathy due to salicylic acid consumption, was not found in any of the patients studied.