British Journal of Anaesthesia 114 (6): 951–7 (2015)

doi: 10.1093/bja/aev064
Advance Access Publication 23 March 2015
Quality and Patient Safety

Q U A L I T Y A N D PAT I E N T S A F E T Y

Defining competence in obstetric epidural anaesthesia

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for inexperienced trainees†
E. J. Drake1,*, J. Coghill1 and J. R. Sneyd1,2
1
Department of Anaesthesia, Derriford Hospital, Derriford Road, Plymouth PL6 8DH, UK, and 2Plymouth
University Peninsula Schools of Medicine and Dentistry, PL6 8BU, UK
*Corresponding author. E-mail: elizabeth.drake@nhs.net

Abstract
Background: Cumulative sum (CUSUM) analysis has been used for assessing competence of trainees learning new technical
skills. One of its disadvantages is the required definition of acceptable and unacceptable success rates. We therefore monitored
the development of competence amongst trainees new to obstetric epidural anaesthesia in a large public hospital.
Methods: Obstetric epidural data were collected prospectively between January 1996 and December 2011. Success rates for
inexperienced trainees were calculated retrospectively for (1) the whole database, (2) for each consecutive attempt and (3)
each trainee’s individual overall success rate. Acceptable and unacceptable success rates were defined and CUSUM graphs
generated for each trainee. Competence was assessed for each trainee and the number of attempts to reach competence
recorded.
Results: Mean () success rate for all inexperienced trainees was 76.8 (0.1%), range 63–90%. Consecutive attempt success rate
produced a learning curve with a mean success rate commencing at 58% on attempt 1. After attempt 10 the attempt number had
no effect on subsequent success rates. From these results, the acceptable and unacceptable success rates were set at 65 and 55%
respectively. CUSUM graphs demonstrated 76 out of 81 trainees competent after a mean of 46 (22) attempts.
Conclusions: CUSUM is useful for assessing trainee epidural competence. Trainees require approximately 50 attempts, as
defined by CUSUM, to reach competence.

Key words: anesthesia regional; competence; epidural; learning curves; obstetric

Editor’s key points In the NHS, training and the delivery of patient care are closely
linked and the majority of training occurs in a service environ-
• CUSUM analysis can be used to monitor performance in an-
ment. Before Modernising Medical Careers and the introduction
aesthesia and surgery
of the European Working Time Regulations, the majority of this
• Monitoring the success of training in technical skills should
learning was experiential and required long hours delivering
be routine for trainees and supervisors alike
service.1 The reduction in working hours has necessitated
• CUSUM thresholds (benchmarks) will vary according to
changes in medical education. There is now a need for compe-
their purpose
tence-based training and robust methods to evaluate training.2
• This study is consistent with others showing that most an-
Competence is the ability of an individual to do a job properly.
aesthetic technical skills require at least 30–50 procedures
The issue of acquiring competence in new procedures has troubled
to gain competency
trainers for many yrs.2 3 After the loss of the apprenticeship

†
This article is accompanied by Editorial Aev142.
Accepted: January 6, 2015
© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com

951
952 | Drake et al.
method of training, Modernising Medical Careers introduced
workplace-based assessments (WPBAs) to assess competence
of trainees.4 There is currently no universally accepted and com-
prehensive way to assess competence in a procedural skill, and
WPBAs have not been shown to improve performance, whereas
cumulative sum (CUSUM) analysis is a statistical method that in-
vestigates the outcome rather than the process of performing a
procedural skill.2 4 WPBAs are snapshots of the training episode
and are not sensitive in the early recognition of the trainee who is
struggling.5 CUSUM has been suggested to fill this role and allow
early remediation of the trainee.5 6
The CUSUM chart allows the observer to decide whether a
production process is in control (i.e. production is within a de-
fined quality boundary) or it has become out of control, at
which point the process needs to be halted, as quality has de-
creased below acceptable limits.6 CUSUM graphs have been
used for many anaesthetic procedural skills including regional
anaesthesia, vascular cannulation and tracheal intubation.3 7–9
CUSUM analysis lends itself to the surveillance of performance
in virtually all aspects of procedural health care, with the proviso
that acceptable success and failure rates can be defined.
We therefore used a large departmental obstetric anaesthetic
database to develop a definition of competence for obstetric
epidural catheterization.
Methods
Since 1996, the anaesthetic department at Derriford Hospital,
Plymouth, has rigorously collected data from all obstetric anaes-
thetic interventions including all neuraxial anaesthetic techni-
ques. Data were entered on the database by one consultant
anaesthetist, who, by using the birth register, ensured that no an-
aesthetic interventions were missed. Patient follow up data and
an independent assessment of success of the epidural by the at-
tending midwife were recorded.
Data from January 1996 to December 2011 from all obstetric
epidurals by all trainees with no prior experience of obstetric an-
aesthesia were extracted. Success rates were calculated. Accept-
able and unacceptable success rates were defined and used to
construct CUSUM graphs to define competency.
Ethics and data protection
Application was made to Plymouth Hospital NHS Trust’s
Research and Development Department. Full ethical approval
was deemed not necessary and the project was registered as an
Audit. Data handling was discussed with the Caldicott Guardian.
All patient data were anonymized. Trainees were identified by
numerical codes known only to the investigator. The database
was encrypted, password protected and stored on a single com-
puter with password access.
Database handling
The obstetric anaesthetic Microsoft Access® database includes
any anaesthetic intervention on delivery suite or in maternity op-
erating theatres. Each record represents an attempt at anaesthe-
sia or analgesia for a parturient. All mothers are followed up after
delivery to ensure that they have no residual problems after an-
aesthetic intervention. Problems were recorded as free text. This
field was further categorized to allow accurate data analysis.
Novices in obstetric anaesthesia were identified from the
database where each trainee has an individual code prefixed
with the stage of training. Hence all novices were identified
from the designated ‘novice’ prefix. Novice data were then ex-
ported onto trainee-specific Microsoft Excel® spreadsheets.
To ensure that the data had been correctly extracted from the ori-
ginal database the results were then checked manually.
Exclusions
In order to explore the full transition from novice to competency,
novice trainees with less than 91 neuraxial procedures were ex-
cluded from the study.
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Definition of epidural success or failure
Information on the success or failure of each obstetric epidural
was extracted from the anaesthetic database. Midwife assess-
ment of the quality of analgesia by the obstetric epidural
throughout both labour and delivery as anything but ‘good’ was
regarded as a ‘failure’. If spinal or general anaesthesia was used
for operative delivery (unless for obstetric reasons a very rapid
delivery was required where it would be impossible to provide
epidural anaesthesia in time), then the obstetric epidural was de-
scribed as a ‘failure’. If there was any other additional analgesia
(e.g. additional systemic opioid for labour or operative delivery),
then the obstetric epidural was described as a ‘failure.’ The data-
base also included a field labelled ‘problems’. If data, (e.g. dural
puncture, post-dural puncture headache, neuropraxia) were en-
tered in any of the problem group categories then the obstetric
epidural was regarded as a failure.
Statistical analysis
Success rate calculations
Mean success rates for obstetric epidurals were calculated from
all obstetric epidural catheterizations attempted by novice trai-
nees. Success rates for each consecutive attempt were calculated.
To investigate whether there was any difference in success rates
once the trainee has had a developmental period to reach compe-
tency, skill linear regression was applied to the first 100 attempts.
Statistical modeling, using the statistical program R, was applied
to the data collected. The model was refitted removing the initial
attempts until the slope parameter was zero. This was the point
at which the attempt number has no bearing on subsequent suc-
cess rate.
Construction of CUSUM graphs
The overall trainee success rate was established and used to de-
termine the acceptable and unacceptable success rates. CUSUM
plots were generated with the acceptable success rate set at
65% and the unacceptable success rate set at 55%. As a compari-
son, CUSUM plots were also generated using the more rigorous
acceptable success rate of 80% and unacceptable success rate of
70%. The number who reached competence and the number of
attempts required to achieve this were determined. Competency
was achieved when the graphical trend fell below two adjacent
calculated boundary lines (h0 ; 2h0 ; 3ho ; 4h0 : : :::) Competency
was lost if the graph ascended and crossed two calculated bound-
ary lines.7 10 (Fig. 1).
Results
Results from the database
During the period January 1996 to December 2011, there were
105 ‘novice’ trainees who attempted 13747 obstetric neuraxial
 Defining competence in obstetric epidural anaesthesia | 953

0.00
CUSUM 2h0 4h0
h0 3h0 5h0
–5.00

–10.00
CUSUM

–15.00

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–20.00

–25.00
0 20 40 60 80 100 120
Number of attempts

B
6.00
5.00
4.00 CUSUM h0 h1

3.00
2.00
CUSUM

1.00
0.00
–1.00
–2.00
–3.00
–4.00
0 20 40 60 80 100 120
Number of attempts

Fig 1 CUSUM plots from two novice trainees learning obstetric epidural anaesthesia. (The unacceptable and acceptable success rates were set at 65 and 55%.) Plot A –
a novice learner who becomes competent on attempt 31 and Plot B – a slow learner never reaching competence. The calculation of boundary lines h0 and h1 and their
significance are explained in Appendix 1.

(epidural, continuous spinal epidural, and spinal) procedures, Epidural success rates
with an overall epidural success rate of 77%. Twenty four of
Success rates
the 105 ‘novice’ trainees had between 1 and 90 records, median
Figure 3 describes success rates for the first 100 obstetric epidural
46 (range 1–86) obstetric neuraxial procedures). None had com-
attempts (or all the attempts if trainees had less than 100 at-
pleted an obstetric anaesthetic training block, typically because
tempts.) Linear regression was applied to subsets of the data
of changes in rotation. These 24 were excluded from the final
from attempt 1 to attempt 100. A zero slope parameter was
analysis. This left 81 novice trainees who had performed
found at attempt 10. Subsequent attempts have a constant suc-
more than 90 obstetric neuraxial procedures for final analysis
cess rate of 77%. Overall dural puncture rate was 0.67%; there
(Fig. 2). All had completed an obstetric anaesthesia training
were no neuropraxias reported.
module.

Attempt data CUSUM plots

Novice trainees attempted a median 119 (range 46–395) obstetric Figure 1 displays sample CUSUM plots for two of the trainees –
epidural catheterizations during the study period. one who reaches competence and one who does not. Table 1
954 | Drake et al.
34164 patient records in obstetric
anaesthesia database from January
1996 to December 2011
13747 patient records identified
for 105 novice trainee
anaesthetists.
81 novice trainees with > 90
entries each in database giving
13553 records. All had completed
the obstetric anaesthetic module
Epidural Spinal
10613 records used 1914 records
for final analysis (excluded)
Fig 2 Flow diagram describing the distribution of patient records amongst anaesthetists. Novice trainees are trainees with no experience in obstetric neuraxial
procedures.
displays the number of trainees reaching competence with two
different failure rates. Use of the 80% acceptable success rates
produces a smaller number of trainees (46/81) reaching compe-
tence than using the more generous 65% acceptable success
rate (77/81). The mean number of attempts to competency is
much lower in the 65% acceptable success rate group than the
80% acceptable success group (46 vs 77 attempts).
Do overall failure rates correlate with trainees who
eventually reach competence?
Table 2 summarizes obstetric epidural data from the five trainees
with the lowest overall success rates and one additional trainee
with a lower success rate who did not achieve competence. For
the five trainees with the lowest success rates, the success rates
ranged between 63 and 66%. Of the whole cohort (n=81) studied,
there were four non-competent trainees as defined by CUSUM
analysis using an acceptable success rate of 65%. Three of the
four non-competent trainees had the lowest overall success
rates. The exception was trainee 6 who was also not competent.
This trainee had the least obstetric epidural attempts (only 46) in
20417 patient records identified
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for experienced anaesthetists
(excluded.)
24 trainees with ≤ 90 entries each
in database giving 194 excluded
patient records. None completed
the obstetric anaesthetic module.
Combined spinal and
epidural (CSE)
1026 records
(excluded)
the database. This trainee was included in the analysis because
they had attempted more than 90 obstetric neuraxial procedures
and had completed a training block. Their overall obstetric epi-
dural success rate was 70%. This trainee had the 15th lowest over-
all success rate. Lack of obstetric epidural attempts is a factor in
this trainee not reaching competency and with more attempts
they might have achieved competency. The two trainees who
were eventually described as competent took 114 attempts. It
could be inferred from this that, if the overall success rate for a
trainee is greater than 70%, then the trainee is likely to be compe-
tent as defined by CUSUM.
Discussion
This is the largest sequential series of anaesthesia trainees learn-
ing obstetric epidural insertion and management. Previously, the
largest cohort for a study in obstetric epidural anaesthesia and
CUSUM was 13.7 Our database included all novice trainees, giving
valuable insight into a whole cohort with varying abilities. The
success or failure assessment was made independently of the
trainee inserting the obstetric epidural and is therefore less
 Defining competence in obstetric epidural anaesthesia | 955

90%

85%

Success rate 80%

75%

70%

65%

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60%

55%
0 10 20 30 40 50 60 70 80 90 100
Attempt number

Fig 3 Mean success rate for the first 100 attempted obstetric epidurals (or all attempts if trainees had less than 100 records in the database) for 81 novice trainees.
There is an initial rapid increase in success rate with the early attempts which then flattens off. The horizontal line describes a constant success rate of 77% where
after attempt 10 the slope parameter of the regression line was zero.

Table 1 Progression to competence by CUSUM for different Table 2 Obstetric epidural data from the trainees with the five
minimum acceptable success rates in boundary lowest overall success rates and one other trainee who did not
reach competence
65% acceptable 80% acceptable
success rate success rate Trainee Overall Total Number of epidural
success rate number of attempts to reach
Mean attempts to reach 46 77
( percentage) epidural competence by
competency
attempts CUSUM
Median attempts to reach 39 65
competency 1 63 137 Not competent
Range 19–114 29–198 2 65 80 Not competent
Number of trainees 77/81 46/81 3 65 120 114
competent after 4 65 115 114
obstetric anaesthetic 5 66 93 Not competent
training block 6 70 46 Not competent
Number of trainees (%) 4 (5.2) 35 (43.2) (only attempted
not competent after 46 epidurals out
obstetric anaesthetic of >90 neuraxial
training block procedures.)

definition, at that time, unknown. Quoting an average is arguably

prone to reporting bias. A single performance of a procedure may
be reliably assessed by training observers using checklists and
rating scales.11 However such qualitative analysis does not ad-
dress overall competence as the latter requires the demonstrated
ability to successfully deliver a procedure on multiple occasions
to a defined standard.
The results of this study have changed practice in our depart-
ment. Novice trainee anaesthetists are not permitted to work
alone until they have completed a minimum of 10 obstetric epi-
durals (where it can be anticipated that the average success rate for
each subsequent attempt is more than 75%.) Our consent process
explains the identity of the operator as a medically qualified
trainee. Risks are explained in general terms and we offer an
overall complication rate rather than one that is trainee specific.
There may be a case for changing this but we would also acknow-
ledge that for a novice trainee the individual success rate is by
unhelpful as the individual trainee might be very dextrous (or
particularly inept).
What acceptable success rate should be used
in investigating trainee competence?
To decide the minimum acceptable success rate pragmatically,
one could use the lowest trainee’s overall success rate (63%).
This trainee was in fact assessed as clinically competent using
current methods of trainer supervision. If the minimum accept-
able success rate for novices was set at 65% and the unacceptable
success rate as 55%, then 95% of all trainees are deemed compe-
tent by CUSUM.
The change in numbers of trainees reaching competency with
different acceptable and unacceptable success rates has previously
956 | Drake et al.
been reported.12 13 If 80% was used as the minimum acceptable
success rate when plotting the CUSUM graphs only 57% of all trai-
nees would be defined as competent and a very large number of
trainees would fail the obstetric module. It is unlikely that all
these trainees are truly incompetent, and setting a lower min-
imum success rate allows a more realistic number of trainees to
pass the assessment. It is unknown whether patient safety is
affected by assessment criteria in training.5
Our acceptable success rate of 65% is more generous, though
the definition of success is more rigorous than previously re-
ported. Kestin recommended failure rate of 5–10%,3 others
20–40%.8 14 Our study used a lower acceptable success rate be-
cause data collection in this study is more robust and less
prone to reporting bias. All the preceding studies have used
data collected by the trainees themselves7 8 12 15 16 and they prob-
ably overestimate the success of the procedures they perform. In
contrast, our assessment of success is made independently by
the midwife and this method of data collection makes the
study unique. Success of an obstetric epidural for this study
was defined as good analgesia for labour and delivery, whilst earl-
ier studies recommending lower acceptable success rates used
less rigorous definitions of a successful obstetric epidural.7 15
The cohort of trainees in our study were novices in the skill and
hence the boundaries set should be generous. Runcie and collea-
gues17 recommended tight acceptable success rates for trained
experienced doctors and widening boundaries for trainees with
less experience in the skill. However, the use of lower acceptable
success rates for beginners may mean that some trainees are
deemed competent when they actually require remediation or
retraining, and detection of their difficulties may be delayed.
Risk adjusted CUSUM charts have been described in the med-
ical literature.18 19 These avoid the need for the definition of the ac-
ceptable and unacceptable failure rates and take other cofounders
which are out of the trainees control into account. Thus should a
trainee have a run of difficult epidurals not because of lack of skill
but because of patient characteristics then the difficult character-
istics are taken into account whilst plotting the CUSUM chart. This
may be useful should CUSUM charts be used prospectively for
training and represents and area for future research.
How many obstetric epidurals do trainees need
to perform?
The mean (range) number of obstetric epidurals needed to reach
competence was 46 (19–114). It can be concluded that from these
results that trainees should expect to complete at least 50 obstet-
ric epidurals to ensure that they are competent and often will
need more. These numbers are consistent with previously pub-
lished data.3 7 8 15
The average overall obstetric epidural success rate calculated
from our database for novice trainees was 77%. Scott and collea-
gues20 reported a 79% success rate in novice epiduralists and
Crawford and colleagues21 reported 79% albeit using different
measures of success. Other studies include experienced epidur-
alists and hence their success rates are higher.22–25
In the cohort studied only 4 from 81 were not deemed compe-
tent if the minimum acceptable success rate was set at 65%
(Table 1). Investigating the four trainees who did not reach com-
petence, it could be concluded that having a low overall success
rate correlates strongly with non-competence (Table 2). Prospect-
ive plotting of CUSUM graphs would pick up the outliers who
need more practice to reach competence.
The study has overcome some of the problems reported in the
literature, namely small trainee cohorts, self-reporting of success
of obstetric epidural and definition of success-of-epidural, which
enhances the validity of our analysis. The limitation of our study
is its retrospective nature, although it would be difficult to
achieve such a large cohort of trainees and such a complete set
of data if the study had been attempted prospectively and
would introduce reporting bias should the data be collected by
trainees involved.3 7 Adverse events were reported as freehand
text and may have been missed. Some of the trainees may have
had a prior exposure to non-obstetric epidural anaesthesia in
general theatres before their obstetric training. This may affect
success rates and the rate at which competence is reached.
The use of CUSUM in learning obstetric epidural anaesthesia
could provide benefits to patients, trainees and trainers alike. Our
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data and analysis succeeds in defining early success rates for ob-
stetric epidurals and should lead to a similar series of analyses
that begin to define early success rates for other practical proce-
dures. Epidural anaesthesia is harder to learn than other proce-
dures15 and procedure specific boundary conditions will be
required.
Conclusions
We found CUSUM an effective tool in charting the development
of competence for trainees in obstetric epidurals. Results of this
study suggest that there is little improvement in epidural success
rates after attempt 10 and to achieve competence a trainee needs
to perform at least 50 epidurals.
Authors’ contributions
J.C. contributed to data collection and data entry to the database.
E.D. contributed to the study design, data analysis and drafting
the paper. J.S.R. contributed to the study design, drafting and re-
vising of the paper.
Declaration of interest
E.D. and J.C. – none declared. J.R.S. – has just left the BJA board.
References
1. Temple PSJ. Time for Training - A Review of the impact of the
European Working Time Directive on the quality of training.
2010: http://wwwmeenhsuk/PDF/14274%20Bookmark%20
Web%20Versionpdf (accessed 10 July 2014)
2. Bould M CN, Naik V. Assessment of procedural skills in anaes-
thesia. Br J Anaesth 2009; 103: 472–83
3. Kestin IG. A statistical approach to measuring the compe-
tence of anaesthetic trainees at practical procedures. Br J
Anaesth 1995; 75: 805–9
4. Starkie T, Drake EJ. Assessment of procedural skills training
and performance in anesthesia using cumulative sum ana-
lysis (cusum). Canadian Journal of Anaesthesia=Journal
Canadien D’anesthesie 2013; 60: 1228–39
5. Lanigan C BR. CUSUM scoring theory and practice. Bulletin of
the Royal College of Anaesthetists 2009; 54: 16–9
6. Bolsin S, Colson M. The use of the Cusum technique in the
assessment of trainee competence in new procedures.
International Journal for Quality in Health Care: Journal of the
International Society for Quality in Health Care/ISQua 2000; 12:
433–8
7. Naik VN, Devito I, Halpern SH. Cusum analysis is a useful tool
to assess resident proficiency at insertion of labour epidurals.

Canadian Journal of Anaesthesia=Journal Canadien D’anesthesie
2003; 50: 694–8
8. de Oliveira Filho GR. The construction of learning curves for
basic skills in anesthetic procedures: an application for the cu-
mulative sum method. Anesthesia and Analgesia 2002; 95: 411–6
9. Barrington MJ, Wong DM, Slater B, Ivanusic JJ, Ovens M. Ultra-
sound-guided regional anesthesia: how much practice do no-
vices require before achieving competency in ultrasound
needle visualization using a cadaver model. Reg Anesth Pain
Med 2012; 37: 334–9
10. Chang WR, McLean IP. CUSUM: a tool for early feedback about
performance? BMC Medical Research Methodology 2006; 6: 8
11. Wong DM, Watson MJ, Kluger R, et al. Evaluation of a task-
specific checklist and global rating scale for ultrasound-
guided regional anesthesia. Reg Anesth Pain Med 2014; 39:
399–408
12. Sivaprakasam J, Purva M. CUSUM analysis to assess compe-
tence: what failure rate is acceptable? The Clinical Teacher
2010; 7: 257–61
13. Sivaprakasam J, Purva M. Should OAA/RCoA provide guide-
lines for using CUSUM analysis to assess competence? Int J
Obstet Anesth 2010; 19: S12
14. Murgatroyd H, McLure H. P57 Audit using CUSUM charts:
widening repertoire of obstetric epidural. Int J Obstet Anesth
2010; 19: S43
15. Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning
manual skills in anesthesiology: Is there a recommended
number of cases for anesthetic procedures? Anesthesia and
Analgesia 1998; 86: 635–9
16. Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia ‘learn-
ing curve’. What is the minimum number of epidural and
spinal blocks to reach consistency? Regional Anesthesia 1996;
21: 182–90
17. Runcie CJ. Assessing the performance of a consultant anaes-
thetist by control chart methodology. Anaesthesia 2009; 64:
293–6
18. Steiner SH, Cook RJ, Farewell VT, Treasure T. Monitoring sur-
gical performance using risk-adjusted cumulative sum
charts. Biostatistics (Oxford, England) 2000; 1: 441–52
19. Spiegelhalter D, Grigg O, Kinsman R, Treasure T. Risk-
adjusted sequential probability ratio tests: applications to
Bristol, Shipman and adult cardiac surgery. International
Journal for Quality in Health Care: Journal of the International
Society for Quality in Health Care/ISQua 2003; 15: 7–13
20. Scott NL, Lewis EJ, Murgatroyd H, Purva M. How good are we at
placing epidurals? Initial results from the Cusum project. Int J
Obstet Anesth 2011; 20: S18
21. Crawford JS. The second thousand epidural blocks in an ob-
stetric hospital practice. Br J Anaesth 1972; 44: 1277–87
22. Pan PH, Bogard TD, Owen MD. Incidence and characteristics
of failures in obstetric neuraxial analgesia and anesthesia: a
retrospective analysis of 19,259 deliveries. Int J Obstet Anesth
2004; 13: 227–33
23. Eappen S, Blinn A, Segal S. Incidence of epidural catheter re-
placement in parturients: a retrospective chart review. Int J
Obstet Anesth 1998; 7: 220–5
Defining competence in obstetric epidural anaesthesia | 957
24. Paech MJ, Godkin R, Webster S. Complications of obstetric
epidural analgesia and anaesthesia: a prospective analysis
of 10,995 cases. Int J Obstet Anesth 1998; 7: 5–11
25. Ware C-L, Oliver M, James S, Collis RE. Quality assuring an
epidural service using CUSUM. International Journal of
Obstetric Anesthesia 2010; 19: S47
Appendix: Construction of CUSUM graphs
To construct the CUSUM chart the variables required are the ac-
ceptable (f o ) and unacceptable (f 1 ) failure rates and reasonable
probabilities of type I and II errors (α and β). The CUSUM graphic-
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al trend is calculated as follows:
Sn ¼ ΣðXn  f0 Þ where Xn ¼ 0 for success and 1 for failure, n is
the number attempted, and f0 = the acceptable failure rate.
The CUSUM graph is then plotted with attempt number on the
x-axis and the CUSUM along the y-axis.
To calculate the boundary lines, h0 and h1 , the following for-
mulae is used:
b
h0 ¼
PþQ
a
h1 ¼
PþQ
Where:
   
f1 1  f0 lnð1  βÞ lnð1  αÞ
P ¼ ln ; Q ¼ ln ; a¼ ; b¼
f0 1  f1 α β
The type I and II errors were set at 0.1. By setting type I and II er-
rors equal, h0 ¼ h1 , and subsequent boundary lines are multiples
of h0 : Type I error is the risk of declaring competence when it is
not achieved and a type II error is the risk of not declaring compe-
tence when it is achieved.
The chart starts at zero and the plotted line will move upwards
with a failure and downwards with a success. A negative trend
line depicts success and a positive trend suggests failure. If the
line crosses the upper decision limit (h1 ) from below, then the
failure rate is significantly greater than the acceptable failure
rate. If a line crosses the lower decision limit (h0 ) from above,
then the true failure rate does not differ significantly from the
acceptable failure rate.8 If the CUSUM remains between two
boundary lines, the results are indeterminate and the null hy-
pothesis cannot be accepted or rejected, and more observations
are required.3 Competency is achieved when the graphical
trend decreases below 2 adjacent calculated boundary lines
(h0 ; 2h0 ; 3ho ; 4h0 : : :::) Competency is lost if the graph ascends
and crosses two calculated boundary lines.7 10
For clarity and consistency we have referred to success rates
(i.e. 100% - failure rate) throughout our manuscript.
Handling editor: P. S. Myles