Training for Norplant implant removal: assessment of learning curves and competency.

OBJECTIVE: To determine the learning curves and rapidity with which clinicians become competent in implant removal using two Norplant removal techniques. METHODS: Twenty-four physicians, none of whom were experienced in the use of Norplant implants, were randomly assigned to learn either the "U" removal technique or the standard technique. The physicians in the two groups received identical training in all other respects. Each physician then performed ten supervised removals. Removal times, procedure problem rates, and the number of procedures performed by the clinicians before they were judged "competent" were assessed for both groups. RESULTS: Data from 240 removals were analyzed. Mean removal times were 38% faster in the "U" group than in the standard group. None of the "U" group procedures took longer than 20 minutes, compared with 11% of removals in the standard group (P < .001). The mean number of cases required before the provider consistently performed all steps adequately was significantly (P < .02) higher in the standard group (5.8 cases) than in the "U" group (3.9 cases). CONCLUSIONS: Using competency-based training methods, the "U" removal technique was learned easily by inexperienced clinicians. It appears to offer significant improvements in speed and achievement of proficiency over the standard technique recommended by the manufacturer. Large-scale programs should consider using competency-based training and the "U" technique as the removal method of choice when providing training in implant removal.

Usefulness of a clinical scoring system to anticipate difficulty of Norplant removal.

OBJECTIVES: Removal of contraceptive implants (e.g. Norplant) is an issue affecting its worldwide acceptability. Reports of difficult, painful removals have resulted in lawsuits and reduced demand. To improve quality of care, we developed a scoring system to anticipate difficult removals. We report on the usefulness of such a system and present client perspectives about the removal experience. METHODS: A 9-point scoring system based on the visibility, arrangement, and position (VAP) of Norplant capsules was used to assess the anticipated difficulty of removal in 53 consecutive patients. The VAP score was then correlated with removal time and related parameters. RESULTS: Mean removal time was 14.74 min (range 4.75-47). In 20% of patients, the VAP score indicated a potentially difficult removal and the VAP score correlated significantly with removal time (r = 0.3, p = 0.05). Patients expected removal to be moderately difficult (mean visual analog score 4.7 out of a possible 10), but after removal they rated the actual removal experience as relatively easy (mean score 2.6/10). Before the removal, only 48% of patients said they would recommend Norplant to a friend but after removal, 70% said they would do so. CONCLUSIONS: A scoring system such as the VAP score can help identify potentially difficult removals so that an experienced remover can be present at the time of removal or an appropriate referral made. However, the VAP score cannot predict variables such as the density of the subcutaneous fibrous tissue "envelope". Although patient anxiety concerning removal may be high, the presence of a competent remover and an easy removal experience reduces this anxiety and encourages patients to be more positive about this method. The value of having properly trained, competent personnel available to perform removals cannot be over-emphasized.

Technical developments in the provision of school meals.

This paper first describes traditional methods of providing school meals and the difficulties associated with those methods. Newer methods including convenience products, cook-freeze and cook-chill systems are described together with their effects on microbial growth, nutrient retention and food sensory properties.

Portion sizes, preparation and cooking yields, and plate waste in school meals.

Available portion sizes for a wide range of menu items were measured in seven junior schools and three senior schools in one local authority area. Serving waste was also measured and used as a criterion of acceptability. Portion sizes for entrees, desserts and potatoes were generally acceptable except for a few unpopular items. Custard was the most acceptable milky sauce. A small range of vegetables was acceptable in small quantities, but excess was rejected while others were almost totally rejected. Peeling, trimming and cooking yields for vegatables, trimming and cooking yields for meat, and plate waste were measured over one year in 180 schools in eight local authority areas. Results for vegetables compared favourably with previously published data except for new potatoes where the yield after machine peeling was lower. Cooking yields for pork, beef and lamb were slightly lower than previously published values. Trimming waste from meat for stewing was substantially greater than the 5 per cent visible fat which is the catering specification for ordering. The mean plate waste was 33 g per child meal (excluding bones).