An observational study of skill retention and practice adoption after a workshop on ultrasound-guided neuraxial anaesthesia

Editor, Ultrasound-guided neuraxial anaesthesia is advantageous due to associated-improved anaesthesia efficacy and increased first-pass success rates.1 Currently, the optimal model to teach competency for ultrasound-guided neuraxial anaesthesia is unclear. Workshops teaching ultrasound-guided neuraxial anaesthesia are offered at international conferences, for example at Euroanaesthesia 2017, Anesthesiology 2016, Society for Obstetric Anesthesia and Perinatology Annual Meeting 2017. The ability of such workshops to teach retainable information on ultrasound-guided neuraxial anaesthesia that is integrated into clinical practice has not been assessed. We conducted a small prospective observational study to assess the skill retention and practice adoption after a conference-style workshop teaching ultrasound-guided neuraxial anaesthesia to anaesthetists of all levels in a tertiary medical centre. Each workshop was given by a leader in ultrasound-guided with vast experience at workshop teaching (JCAC or SHH). The study received ethical approval from Hadassah Hebrew University Medical Center Ethics Committee, chair person Prof Tova Chajek for a waiver for signed consent (0508-13-HMO 27 January 2013). 34 novice ultrasound-guided anaesthesia practitioners in a single centre participated in one of two ultrasound-guided neuraxial anaesthesia workshops. The workshop started with a 45-min audiovisual lecture, which presented the sonoanatomy, and the standardised technique of ultrasound assessment of the spine to identify landmarks first by using the longitudinal paramedian oblique plane and sagital oblique views to find the intervertebral space and then by using the transverse view to find the midline.2 This audiovisual lecture was followed by a 45-min hands-on session with an expert instructor. Nineteen (56%) participants agreed to further follow-up. No further teaching intervention was imparted after conclusion of the workshop. Participants were assessed by a single assessor immediately following the workshop, 3 months after the workshop and at 6 months following the workshop using a technical skills global rating Likert scale modified for ultrasound-guided neuraxial anaesthesia (1 = very poor, 5 = clearly superior). The primary study outcome was the participants’ ability to correctly identify the insertion point for neuraxial anaesthesia using ultrasound-guided. Secondary outcomes were confidence in performing ultrasound-guided, interpretation of images and number of procedures performed. In the statistical analysis we performed the Sign to compare the overall skill at baseline, to 3 months and to 6 months. Data were analysed using IBM SPSS version 21.0.0 for Windows (IBM Corp., Armonk, New York, USA). Results were considered significant if P less than 0.05. Scores were high at baseline and returned to this level by 6 months. There was a significant decrease in overall score based on a participant's ability to find the optimal insertion point between baseline and 3 months, P = 0.006, but there was no difference between overall score at baseline and 6 months, P = 1.0. Results for other parameters are shown in Table 1. Cumulative ultrasound use in clinical practice increased throughout the study period with 14 individual uses at the first assessment and 74 individual uses by the end of the study. Four participants reported using ultrasound-guided 12 times (the maximum number of times ultrasound-guided was used by an individual participant during the study period). Participants’ scores for optimal insertion point identification at each assessment are shown in Fig. 1.Table 1: Participant's scores at each assessment for primary and secondary outcomesFig. 1: Participants’ scores for optimal insertion point identification at each assessment.The main reason cited at the end of the study for not using ultrasound-guided routinely on the labour ward was the lack of ultrasound availability. In contrast, in the main operating rooms, it was due to time constraints and only finding ultrasound-guided helpful in difficult cases. Previous studies looking at the learning curve of novice anaesthesiologists performing a generic ultrasound skill showed a sustained improvement over the first 10 ultrasound scans.3 A similar study looking at ultrasound-guided axillary nerve block showed similar results for the first 10 scans and then a plateau in improvement between scans 10 and 15.4 Competency in ultrasound-guided neuraxial anaesthesia has previously been achieved between 18 and 36 scans.5 These prior studies utilised a shorter follow-up period than our 6 months. The effects of time and particularly ‘slow’ learning and offline effects may well explain why there were improved performances between 3 and 6 months in our study participants and why they gained competency with lower numbers of scans than reported previously.6 The current study has several limitations, most notably the small number of participants and that only 56% consented to further follow-up. The workshop was open to the anaesthesia, pain medicine and critical care departments. Most of those who did not consent to further follow-up were primarily physicians who did not work regularly in the operating room or labour ward. This adds an element of selection bias into our study and as such the results should be interpreted with caution. Although much more work is needed in this area, ultrasound-guided neuraxial anaesthesia appears to be a skill that can be learned in a workshop similar to those offered at anaesthesia conferences. Anaesthetists should be aware that their skill level may initially drop before consolidation of practice occurs. Acknowledgements relating to this article Assistance with the letter: Dr Neil Amison performed the data entry of the assessment forms and graded comments about ultrasound use. Financial support and sponsorship: none. Conflicts of interest: none.

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