Characterizing Novice Behavior Associated With Learning Ultrasound-Guided Peripheral Regional Anesthesia

Background and Objectives: Ultrasound-guided regional anesthesia is a rapidly growing field. There exists little information regarding the competencies involved with such a practice. The objective of this exploratory study was to characterize the behavior of novices as they undertook the challenges of learning a new technique. In addition to assessing for both committed errors and accuracy, we aimed to identify previously unrecognized quality-compromising behaviors that could help structure effective training interventions. Methods: By using detailed video analyses, the performances of 6 anesthesia residents were evaluated while on a dedicated 1-month rotation in ultrasound-guided regional anesthesia. From these video reviews, we assessed accuracy, errors committed, performance times, and searched for previously unrecognized quality-compromising behaviors. Results: A total of 520 nerve blocks were videotaped and reviewed. All residents performed at least 66 nerve blocks, with an overall success rate of 93.6% and 4 complications. Both speed and accuracy improved throughout the rotation. There were a total of 398 errors committed, with the 2 most common errors consisting of the failure to visualize the needle before advancement and unintentional probe movement. Five quality-compromising patterns of behavior were identified: (1) failure to recognize the maldistribution of local anesthesia, (2) failure to recognize an intramuscular location of the needle tip before injection, (3) fatigue, (4) failure to correctly correlate the sidedness of the patient with the sidedness of the ultrasound image, and (5) poor choice of needle-insertion site and angle with respect to the probe preventing accurate needle visualization. Conclusions: Based on the analysis of the committed errors and the identification of quality-compromising behaviors, we are able to recommend important targets for learning in future training and simulation programs.

[1]  G. Schuepfer,et al.  Psoas compartment block (PCB) in children: Part II – generation of an institutional learning curve with a new technique 1 , 2005, Paediatric anaesthesia.

[2]  C. McCartney,et al.  Ultrasound guidance for a lateral approach to the sciatic nerve in the popliteal fossa , 2004, Anaesthesia.

[3]  Christoph Konrad,et al.  Learning Manual Skills in Anesthesiology: Is There a Recommended Number of Cases for Anesthetic Procedures? , 1998, Anesthesia and analgesia.

[4]  Getúlio Rodrigues de Oliveira Filho,et al.  The Construction of Learning Curves for Basic Skills in Anesthetic Procedures: An Application for the Cumulative Sum Method , 2002, Anesthesia and analgesia.

[5]  D. Kopacz,et al.  The Regional Anesthesia “Learning Curve”: What Is the Minimum Number of Epidural and Spinal Blocks to Reach Consistency? , 1995, Regional Anesthesia & Pain Medicine.

[6]  D M Long,et al.  Competency‐based Residency Training: The Next Advance in Graduate Medical Education , 2000, Acta neurochirurgica. Supplement.

[7]  Morten Lind,et al.  A Model of Human Decision Making in Complex Systems and its Use for Design of System Control Strategies , 1982, 1982 American Control Conference.

[8]  Get lio Rodrigues de Oliveira Filho,et al.  The construction of learning curves for basic skills in anesthetic procedures: an application for the cumulative sum method. , 2002 .

[9]  Jens Rasmussen,et al.  Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models , 1983, IEEE Transactions on Systems, Man, and Cybernetics.

[10]  R. Fink,et al.  The Acute Myotoxic Effects of Bupivacaine and Ropivacaine After Continuous Peripheral Nerve Blockades , 2003, Anesthesia and analgesia.

[11]  A. Gray,et al.  Ultrasound-guided Regional Anesthesia: Current State of the Art , 2006, Anesthesiology.

[12]  T. P. Wright,et al.  Factors affecting the cost of airplanes , 1936 .

[13]  Pierre Le Morvan,et al.  Medical learning curves and the Kantian ideal , 2005, Journal of Medical Ethics.

[14]  Brian D Sites,et al.  The Learning Curve Associated With a Simulated Ultrasound-Guided Interventional Task by Inexperienced Anesthesia Residents , 2004, Regional Anesthesia & Pain Medicine.