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Abstract

Editor—We thank Drs Srinivasan, O'Brien, and Shorten for their interest in our article. Obstetric epidural practice for the trainee, once deemed competent by experienced trainers, most often occurs out of hours. In this situation, because much of the trainee's work is unsupervised it is difficult to gain an insight on a trainee's performance in a particular procedural skill. Anaesthesia is a speciality in which the trainee is an apprentice. Working alongside a trainer ensures that important skills required in successfully completing a procedural skill are not being omitted by the trainee and seriously affecting patient safety.1Bould M Naik V Assessment of procedural skills in anaesthesia.Br J Anaesth. 2009; 103: 472-483Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar Acquisition of practical skills and then assessment of proficiency are fraught with difficulties in postgraduate education and often require multiple assessment modalities to ensure some accuracy. Often, these assessment methods are ‘real time’ and do not continually assess the trainee's continued proficiency.1Bould M Naik V Assessment of procedural skills in anaesthesia.Br J Anaesth. 2009; 103: 472-483Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar CUSUM was originally designed as a surveillance tool in munitions factories.2Bolsin S Colson M The use of the Cusum technique in the assessment of trainee competence in new procedures.Int J Qual Health Care. 2000; 12: 433-438Crossref PubMed Scopus (218) Google Scholar We use CUSUM here in a similar manner to assess when a trainee initially reaches competency and then as a surveillance tool to investigate whether competency is maintained.3Lanigan C CUSUM scoring theory and practice.Bilt Royal Coll Anaesth. 2009; 54: 16-19Google Scholar We agree that CUSUM does not directly investigate the trainee's continued technique, only final outcome, but it is the only assessment modality that investigates long-term continued proficiency.4Starkie T Drake EJ Assessment of procedural skills training and performance in anesthesia using cumulative sum analysis (cusum).Can J Anaesth. 2013; 60: 1228-1239Crossref PubMed Scopus (28) Google Scholar Its use in an obstetric anaesthetic setting should be real time (not retrospectively from a database as in our study) and used in conjunction with other means of trainee feedback to ensure trainee proficiency, hence the provision of a safe, good-quality service for patient. The results from our study are important because we have demonstrated the pattern of success in the skill acquisition in the first epidurals a trainee inserts. Our use of linear regression to success rates for each consecutive epidural attempt followed by statistical modelling suggests that there is no change in success rate after epidural attempt 10.5Drake EJ Coghill J Sneyd JR Defining competence in obstetric epidural anaesthesia for inexperienced trainees.Br J Anaesth. 2015; 114: 951-957Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar This result is useful for assessing the trainee's readiness for working with minimal support whilst on the on-call rota. Combined with other methods of assessment, if the trainee has had at least 10 attempts at epidural analgesia then it is likely that the trainee should be able to work alone and be able to insert epidurals successfully. The use of a database with the data collected independently, for many years, provides us with data which overcome most of the problems of the previous work in anaesthesia with CUSUM.4Starkie T Drake EJ Assessment of procedural skills training and performance in anesthesia using cumulative sum analysis (cusum).Can J Anaesth. 2013; 60: 1228-1239Crossref PubMed Scopus (28) Google Scholar Obviously, we would agree that poor aseptic technique is unacceptable. Trainees in our institution are watched whilst performing initial attempts at clinical skills, and poor technique is rapidly remediated. We believe that assessment of procedural skill proficiency (i.e. good technique) and comprehensive monitoring of efficacy (i.e. CUSUM) are complementary. A good training programme could usefully combine the two approaches. None declared.