title: Experience is not enough: repeated breaches in epidural anesthesia aseptic technique by novice operators despite improved skill.
abstract: BACKGROUND
  Invasive procedures such as epidural anesthesia carry risks for complications such as erroneous placement arising from inadequate manual skills and infection secondary to breaches in aseptic technique. Although it is assumed that improvement in aseptic technique parallels improved dexterity, this assertion remains unproven. The aim of this study was to determine whether increased proficiency in the manual skills for epidural anesthesia is associated with improved aseptic technique.
  
  
  METHODS
  Second-year anesthesia residents were repeatedly videotaped performing epidural anesthesia over 6-month periods. Three independent examiners blinded to the level of training of the residents evaluated the procedures for manual skills and aseptic technique. Each procedure was graded using a manual skills checklist, a global rating scale, and an aseptic technique checklist. The main outcome measures were the scores for these three tools.
  
  
  RESULTS
  Thirty-five sessions were videotaped over 1 yr. Interrater reliability was nearly perfect. A strong positive association was found between increased experience and manual skills, as reflected by the scores achieved on both the manual skills checklist and the global rating scale. In contrast, a nonsignificant or very weak correlation was found between the aseptic technique checklist total scores and the number of epidurals performed.
  
  
  CONCLUSIONS
  Manual skills for invasive procedures improved with increasing experience, but aseptic technique did not, despite formal teaching. These findings reflect major gaps in the understanding and teaching of the principles of aseptic technique, most likely due to lack of structured training. Educational initiatives are needed to correct these teaching gaps.
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada. zeevfriedman@rogers.com
authors.forename: Zeev
authors.initials: Z
authors.lastname: Friedman
authors.forename: Naveed
authors.initials: N
authors.lastname: Siddiqui
authors.forename: Rita
authors.initials: R
authors.lastname: Katznelson
authors.forename: Isabella
authors.initials: I
authors.lastname: Devito
authors.forename: Sharon
authors.initials: S
authors.lastname: Davies
mesh_terms: D000767:Anesthesia, Epidural / Q000379:methods* / Q000592:standards*; D000776:Anesthesiology / Q000193:education*; D002983:Clinical Competence; D003479:Curriculum; D004502:Education, Medical, Continuing; D004521:Educational Measurement; D006784:Hospitals, Teaching; D006801:Humans; D007396:Internship and Residency; D007858:Learning; D009864:Ontario; D013663:Teaching; D014743:Videotape Recording