Proficiency based progression training for epidural catheter placement for labour analgesia

13 Nov 2018

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 “Pro­fi­ciency-based pro­gres­sion (PBP)” we were able to show improved pa­tient outcomes. Pre­vi­ous in­ves­ti­ga­tions of med­i­cal train­ing using this tool have fo­cused on the per­for­mance of the doc­tor rather than a mean­ing­ful pa­tient out­come.

This study titled “Proficiency-based progression training: an “end to end” model for decreasing error applied to achievement of effective epidural analgesia during labour -a randomized control study”  was published in the Bri­tish Med­i­cal Jour­nal Open (BMJ Open). In de­vel­op­ing the train­ing tech­nique, we se­lected a pro­ce­dure—in this case epidu­ral—and bro­ken it down into a se­ries of “mi­cro­tasks”or “Metrics”. We ob­served both ex­perts and novices in epidu­ral catheter in­ser­tion per­form­ing each mi­cro­task with the fo­cus on what should or should not hap­pen, and at the end of an eight-month process, a se­ries of met­rics emerged.

Anaes­the­sia trainees had to suc­cess­fully demon­strate their com­pe­tence in each met­ric — 74 in all — be­fore pro­gress­ing to the next step or mi­cro­task. For in­stance, one met­ric re­quired the doc­tor to cover an A4-sized area of the pa­tient’s back when paint­ing on asep­tic so­lu­tion. In the event of not meet­ing this re­quire­ment, they were deemed not to have com­pleted the met­ric. Train­ing could not progress un­til the met­ric was met.

This train­ing tool that could mea­sure the trainee’s ef­fec­tive­ness along each tiny step of a pro­ce­dure proved highly ef­fec­tive in our trial. In fact pa­tients of trainees who had trained us­ing this tool re­sponded much more pos­i­tively to epidu­ral com­pared to doc­tors who un­der­went stan­dard sim­u­la­tion based train­ing. The fail­ure rate for those with stan­dard train­ing was 24% com­pared to 12% who used the PBP effectively halving the failure rate (figure 1).

One hun­dred and 40 women took part in the clin­i­cal trial at CUMH be­tween Jan­uary 2015 and Septem­ber 2016. To be el­i­gi­ble, it had to be es­tab­lished that they were in labour and had cho­sen to have an epidu­ral. If the midwife deemed the pa­tient to be com­fort­able within 60 min­utes or less of hav­ing the epidu­ral, the pro­ce­dure was deemed a suc­cess.

The lim­i­ta­tions of the trial were the small sam­ple size and the fact that it took place in just one hospi­tal. How­ever 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.






Department of Anaesthesiology and Intensive Care Medicine