Tool cuts epidural fail rate by over 50% at Cork hospital
The failure rate of epidurals given to women in labour at Cork University Maternity Hospital (CUMH) was reduced by more than 50% through use of a new training tool developed at University College Cork.
George Shorten, professor of anaesthesia and intensive care medicine at UCC, said it was the first time the training tool — known as proficiency-based progression — had been shown to improve patient outcomes.
Previous investigation of medical training have focused on the performance of the doctor rather than a meaningful patient outcome.
The research which led to this finding has just been published by Dr Karthik Srinivasan, Prof Shorten and the UCC team in the British Medical Journal Open (BMJ Open).
In developing the training technique, Prof Shorten said they had selected a procedure —in this case epidural — and broken it down into a series of “microtasks”.
They had 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 and errors 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.
The upshot of a training tool that could measure the trainee’s effectiveness along each tiny step of a procedure proved highly effective in a clinical trial at CUMH, said Prof Shorten.
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.
Prof Shorten said the failure rate for those with standard training was 24% compared to 12% who used the proficiency-based progression.
"The failure rate was halved by using this form of training," Prof Shorten said.
He said it was the first time a trial had shown the proficiency-based progression training tool could benefit patients.
This is an important advance,” he said.
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 in 60 minutes or less of having the epidural, the procedure was deemed a success.
Prof Shorten said the limitations of the trial were the small sample size and the fact it took place in just one hospital.
However, on foot of their findings, he has been invited to the prestigious Johns Hopkins School of Medicine in Baltimore, USA.
“They are interested in our study and they asked me to go there as part of their Distinguished Scholars programme to describe the methods we used and what this means for the future of medical training,” he said.
