Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore.
Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore.
Int J Obstet Anesth. 2020 Nov;44:33-39. doi: 10.1016/j.ijoa.2020.05.002. Epub 2020 May 12.
The epidural anesthesia technique is a challenging skill to master. The Accreditation Council for Graduate Medical Education (ACGME) stipulates that anesthesiology residents must complete 40 epidural procedures by the end of junior residency. The rationale is unknown. The aim of this prospective study was to determine the minimum case experience required to demonstrate competence in performing obstetric combined spinal-epidural procedures among junior residents, using an objective statistical tool, the cumulative sum (CUSUM) analysis.
Twenty-four residents, with no prior experience performing epidurals, sequentially recorded all obstetric combined spinal-epidural procedures as a 'success' or 'failure', based on study criteria. Individual CUSUM graphs were plotted, with acceptable and unacceptable failure rates set at 20% and 35%, respectively. The number of procedural attempts necessary to demonstrate competence was determined.
Twenty-four residents (mean (SD) age 29 (2) years) participated in the study. Median (IQR) number of procedures was 78 (66-85), with a median (IQR) success rate of 86% (82-89%). Nineteen of 24 residents required a median (IQR) of 40 (33-50) attempts to demonstrate competence. Five did not achieve procedural competence in the training period. The CUSUM graphs highlighted performance trends that required intervention.
Competence was achieved by 19/24 residents after the ACGME-required case experience of 40 combined spinal-epidural procedures, based on a predefined acceptable failure rate of 20%. In our experience, CUSUM analysis is useful in monitoring technical performance over time and should be included as an adjunct assessment method for determining procedural competence.
硬膜外麻醉技术是一项具有挑战性的技能。毕业后医学教育认证委员会（ACGME）规定，麻醉学住院医师在住院医师培训的最后阶段必须完成 40 例硬膜外操作。其原理尚不清楚。本前瞻性研究旨在使用累积和（CUSUM）分析这一客观统计工具，确定初级住院医师在实施产科脊髓-硬膜外联合麻醉时所需的最低病例经验，以证明其具备实施该技术的能力。
24 名无硬膜外操作经验的住院医师根据研究标准，将所有产科脊髓-硬膜外联合麻醉操作顺序记录为“成功”或“失败”。绘制个体 CUSUM 图，可接受和不可接受的失败率分别设定为 20%和 35%。确定达到胜任能力所需的操作次数。
24 名住院医师（平均（SD）年龄 29（2）岁）参与了这项研究。中位数（IQR）操作数为 78（66-85），中位数（IQR）成功率为 86%（82-89%）。24 名住院医师中有 19 名需要中位数（IQR）40（33-50）次尝试才能证明胜任能力。5 名住院医师在培训期间未能达到操作能力。CUSUM 图突出了需要干预的性能趋势。
根据 ACGME 规定的 40 例脊髓-硬膜外联合操作的最低病例经验，24 名住院医师中有 19 名达到了胜任能力，可接受的失败率设定为 20%。根据我们的经验，CUSUM 分析有助于随着时间的推移监测技术表现，应将其作为确定操作能力的辅助评估方法之一。
