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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.

Background and aims Efforts to move from time-based to outcome-based training have led to development of novel training methodologies including Proficiency-Based Progression (PBP). Recently, our group has demonstrated that PBP training based on pre-defined metrics improves not just physician performance, but meaningful patient outcome (53% decrease in failure incidence of epidurals placed by anaesthetic trainees). The principal objective of this study is to examine for association (i) quality of performance (in a simulated setting) of epidural insertion by novices following PBP training and (ii) subsequent success in achieving epidural analgesia for labouring parturients. Methods With institutional ethical approval, all trainees in anaesthesiology scheduled to train in obstetric anaesthesia during 2019–2020 will be invited to participate. Following baseline testing, trainees will undertake PBP training with one-to-one supervision of a consultant anaesthetist trained in PBP. Detailed descriptions of pre-defined metrics will be provided. Each will then practice each metric in a simulated setting with metrics-based feedback in real time. Trainees will proceed to the clinical phase when they have attained the pre-defined proficiency benchmark. All subsequent attempts of labour epidural catheter placement will be documented. Overall incidence of success and other performance parameters will be calculated and compared with historical reports. Results This study is still recruiting. We successfully trained three novices who performed 32 labour epidural catheter placements. The proportion of epidural failure was 21.9% (7/32), the proportion of supervisor takeover was 16% (6/32), difficulty to insert epidural due to patient factors was 13% (5/32), patient satisfaction with the epidural performance is 8.6 ± 1.9. Conclusions This study is recruiting.

Spinal anaesthesia performed at levels higher than the L3-4 intervertebral space may result in spinal cord injury. Our aim was to establish a protocol to reduce the chance of spinal anaesthesia performed at or above L2-3.One hundred and ten consenting patients at 32weeks of gestation or greater scheduled for non-emergency caesarean section under spinal anaesthesia were randomly allocated to have needle insertion performed at an intervertebral space determined by one of two landmark techniques. In Group A, if the intercristal line intersected an intervertebral space, this space was selected or if the intercristal line intersected a spinous process the space immediately above was selected. In Group B, if the intercristal line intersected an intervertebral space or a spinous process, the intervertebral space immediately below was chosen. The actual intervertebral space chosen was identified using ultrasound by a blinded investigator.In Group A, an intervertebral space at or above L2-3 was marked in 25 (45.5%) patients compared with 4 (7.3%) in Group B (P0.001). In 5/55 (9.1%) patients in Group A, the intervertebral space initially chosen was L1-2 whereas this occurred in no patient in Group B. There was no difference between groups in number of needle passes or attempts, onset of block at 5, 10 and 15min or need for rescue analgesia.Our data suggest that when performing spinal anaesthesia in pregnant patients, if the intercristal line intersects an intervertebral space then the space below should be chosen and if the intercristal line intersects a spinous process then the interspace below should be chosen. This will reduce the incidence of spinal anaesthesia performed at or above L2-3.