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Revista Brasileira de Anestesiologia

Print version ISSN 0034-7094On-line version ISSN 1806-907X

Rev. Bras. Anestesiol. vol.67 no.5 Campinas Sept/Oct. 2017

http://dx.doi.org/10.1016/j.bjane.2016.08.005 

Scientific Articles

YouTube as an information source of spinal anesthesia, epidural anesthesia and combined spinal and epidural anesthesia

Serkan Tulgar*  1 

Onur Selvi1 

Talat Ercan Serifsoy1 

Ozgur Senturk1 

Zeliha Ozer1 

1Maltepe University Faculty of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey

Abstract

Introduction

Social media as YouTube have become a part of daily life and many studies evaluated health-related YouTube videos. Our aim was to evaluate videos available on YouTube for the conformity to textbook information and their sufficiency as a source for patient information.

Material and method

A search of the YouTube website was performed using the keywords "spinal anesthesia, epidural anesthesia, combined spinal epidural anesthesia". Firstly, 180 videos were evaluated and the characteristics of the video were noted, and the features of the video too were noted if the video was regarding neuraxial anesthesia. Questionnaire 1 (Q1) evaluating the video quality relating to neuraxial anesthesia was designed using a textbook as reference and questionnaire 2 (Q2) was designed for evaluating patient information.

Results

After exclusions, 40 videos were included in the study. There was no difference in Q1 or Q2 scores when videos were grouped into 4 quarters according to their appearance order, time since upload or views to length rate (p > 0.05). There was no statistical difference between Q1 or Q2 scores for spinal, epidural or combined videos (p > 0.05). Videos prepared by a healthcare institute have a higher score in both Questionnaires 1 and 2 (10.87 ± 4.28 vs. 5.84 ± 2.90, p = 0.044 and 3.89 ± 5.43 vs. 1.19 ± 3.35, p = 0.01 respectively).

Conclusion

Videos prepared by institutes, societies, etc. were of higher educational value, but were still very lacking. Videos should be prepared in adherence to available and up-to-date guidelines taking into consideration appropriate step by step explanation of each procedure, patient safety and frequently asked questions.

KEYWORDS Youtube; Anesthesia; Spinal; Epidural

Introduction

Social media and video-sharing websites such as YouTube have become a part of daily life and the number of health-related videos increases daily. YouTube is reported to be the number one source of information on health-related topics, after the patient's physician.1-3 It is known that following patient-physician meetings, patients seek additional information.4

Social media are frequently used by healthcare professionals to follow innovation and advancement in their own field, see other practices, evaluate and send comments to video owners and interact with their peers.5-10 Medical students are also turning to social media, especially video sharing websites such as YouTube, for medical education related materials.11-13

Unfortunately, many studies have demonstrated that the reliability, intelligibility and compliance to standards of many medical videos are not overseen or approved as appropriate or accurate by professionals in their field. Many studies have, therefore, investigated the reliability of internet sources health-related information14-19 as there is a significant risk that patients or their relatives may find missing, false or irrelevant information when they research a health-related topic online. Convincing persons exposed to this information pollution that their source is wrong information and thereafter providing accurate information is more difficult than giving information to a person who has not been exposed to misinformation. On the other hand, small amount of inaccurate information acquired by healthcare professionals may lead to larger problems.

In patients who are due to undergo elective surgical procedures, it is very common for patients to seek information from the Internet or different sources, even after they have been given information by their surgeon and/or anesthesiologist.8,20 It is only natural that patients seek more and more information on a procedure they are due to undergo.

Spinal anesthesia, epidural anesthesia and combined spinal epidural anesthesia are commonly used methods for regional anesthesia. Considering the popularity of video sharing websites such as YouTube, and the view numbers of related videos, there is a high likelihood that patients would seek audiovisual information regarding these procedures too. Also, an important step of development of skills in medical students involves observation of procedures on manikins or patients, before the skill is performed and after it has been learnt from a textbook or via a professional healthcare instructor.21,22

A previous study evaluated the procedural quality of 22 lumbar puncture and 16 spinal anesthesia videos posted on YouTube before March 2009.17 However, to our knowledge, there is no study including spinal anesthesia, epidural anesthesia and combined spinal epidural anesthesia. Our aim was to evaluate videos available on YouTube for the conformity to textbook information and their sufficiency as a source for patient information.

Material and method

A search of the YouTube (http://www.youtube.com) website was performed on 15.12.2015 using the keywords "spinal anesthesia, epidural anesthesia, combined spinal epidural anesthesia". All times, all countries and English language was chosen as the YouTube filter with results to appear from most relevant to least relevant. The first 60 results for each search result were noted.

The first evaluator evaluated 180 videos and noted the date of upload, number of views, length of video, language, relevance to search term, the characteristics of the video and if the video was regarding neuraxial anesthesia, the features of the video.

All authors reached consensus for the study design and exclusion criteria before commencement of this study. Following first evaluation, videos longer than 15 min, videos not related to neuraxial anesthesia, videos not in the English language and repeat videos were excluded from the study.

After initial evaluation and exclusions were performed, five reviewers evaluated the video quality and adequacy as an information source for patients. This evaluation was performed using two questionnaires designed by authors. Reviewers were also asked to classify each video as being either; for medical education, for healthcare professionals, for patient information, product advertisement, institute promotion, confusing, other. The aim of the video was determined as the option at least three reviewers chose. If a classification was not chosen by at least three of the reviewers, then re-classification was performed until at least three reviewers agreed on the classification.

Questionnaire evaluating the video (Q1) quality relating to neuraxial anesthesia was designed using a textbook as reference.23-25 A focus group meeting was performed where all authors reached consensus on the questions for Q1. The second questionnaire (Q2) was designed, using the same method, based on a question and answer page on the American Society of Regional Anesthesia's website, available at: https://www.asra.com/page/41/regional-anesthesia-for-surgery. The questionnaires contained 10 and 5 questions each, respectively. Every evaluation criterion was scored as none, average and good on the basis of certain aspects.

A rubric was available for all raters. For Q1 none, average and good received 0, 1 or 2 points and for Q2 they received 0, 2 or 4 points, respectively. Some items contained two questions. In this case, the raters were instructed to choose none: if both questions were not answered, average: if one was fully and two were partially/inadequately answered, good: if both questions were adequately answered. Therefore, each video received a score ranging from 0-20 points. Scoring was performed using a rubric that each reviewer had access to and was designed by one of the authors. Videos were accepted as being very bad (0-4 points), bad-average (5-8 points), average (9-12 points), good (13-16 points) or very good (17-20 points).

Statistical analysis

Inter Rater Reliability (IRR) was calculated for each video using Fleiss' Kappa for rating score calculator available at https://www.statstodo.com/CohenKappa_Pgm.php. Descriptive evaluation was performed for each video. Kappa < 0 - no agreement, 0.0-0.20 - insignificant agreement, 0.21-0.40 - moderate agreement, 0.41-0.60 - most part agreement, 0.61-0.80 - significantly agreement, 0.81-1.00 - excellent agreement.

All other statistical evaluation was performed using SPSS 16.0 (SPSS, Chicago, IL, USA). U test was used for comparison of medians between two groups. More than one group was compared using ANOVA. Normal distribution was evaluated with Shapiro-Wilk test. The post-hoc-Tukey test was used for comparison of groups with normal distribution and Tamhane test was used for comparison of groups that were not distributed normally.

Results

After exclusions, 40 videos were included in the study. Of these, 23 were related to spinal anesthesia, 10 epidural anesthesia and 7 combined spinal epidural anesthesia. The video evaluation process and videos by exclusion criteria are shown in Table 1. Time since video upload ranged from 0-98 months with an average of 39.6 ± 23.2 m. Average video length was 280 ± 180 s (90-900 s).

Table 1 Selection process (number of videos). 

Search keyword Accepted Rejected
Spinal anesthesia (60) Spinal (23) Did not meet inclusion criteria (12)
Epidural (1) Not spinal but related anesthesia (6)
Combined (2) Not related anesthesia (6)
Duplication (10)
Epidural anesthesia (60) Epidural (9) Did not meet inclusion criteria (19)
Combined (2) Duplication (16)
Not epidural but related anesthesia (2)
Not related anesthesia (12)
Combined (60) Combined (3) Did not meet inclusion criteria (9)
Duplication (34)
Not neuraxial but related anesthesia (3)
Not related anesthesia (11)

Videos were classified as aimed at medical education or health professionals in 24, aimed for patient information in 5, web site promotion in 2, institute promotion in 1 and confusing in 5 videos.

Average score of videos from Questionnaire 1 which measured procedural quality was 7.14 ± 3.88 (0.6-15.4). Eight videos were classified according to Questionnaire 1 scores as being very bad, 19 videos as bad-average, six videos as average and 7 videos were classified as average-good. No video was classified as being very good. Only 2 of 13 videos classified as average or average-good were uploaded by an official organization, such as hospital, institute or society.

When videos were evaluated according to patient information with Questionnaire 2, average score was found to be 1.93 ± 4.13 (0-15.9). One video was classified as being very bad, 3 videos as average and 2 videos as average-good. Seventeen videos received no points from any reviewers. All videos classified as being average or average-good were reported as being patient information videos by the reviewers and all had been prepared by an academic institute or hospital. Videos were grouped as being uploaded by a healthcare institute or not and Questionnaire 1 and Questionnaire 2 results were compared. Videos prepared by a healthcare institute have a higher score in both Questionnaire 1 and 2 (10.87 ± 4.28 vs. 5.84 ± 2.90, p = 0.044 and 3.89 ± 5.43 vs. 1.19 ± 3.35, p = 0.01 respectively). Fig. 1 shows the questionnaire results according to uploading source.

Figure 1 Distribution of questionnaire results according to video uploader. 

There was no difference in Q1 or Q2 scores when videos were grouped into 4 quarters according to their appearance order, time since upload or views to length rate (p > 0.05). There was no statistical difference between Q1 or Q2 scores for spinal, epidural or combined videos (p > 0.05) (Fig. 2).

Figure 2 Distribution of search result sequence (Quarter A), loading time (Quarter B) and views/video length (Quarter C) according to neuraxial anesthesia type. 

Results of evaluation of Q1 and Q2 are given in Figs. 3 and 4. When Q1 was evaluated, 80% of videos did not include step-by-step instructions, 50% did not introduce materials (needle, catheter etc.) to be used, 70% did not include patient monitorization, 50% did not give information on the drugs used or describe the administration of infiltrative anesthesia, over 90% did not mention contraindications and 80% did not mention complications. All videos generally included the video's aim and video content and title were in concordance. 60% of videos partially or fully described the appropriate anatomical structures and close to 80% stressed the importance of sterilization.

Figure 3 Questionnaire for procedural evaluating and distribution of answers. 

Figure 4 Questionnaire for patient information and distribution of answers. 

When Q2 was analyzed, over 80% of videos did not answer any of the questions. Only around 5% of videos could be classified as being good according to Q2.

When videos were evaluated according to sterilization techniques, 13 used betadine, 1 used betadine and isopropyl alcohol, 1 used betadine and spirit, 6 used isopropyl alcohol, and 2 used chlorhexidine for procedure area sterilization. Seven-teen videos did not mention the agent used. Sterile drape was used in 3 of isopropyl alcohol, 1 of betadine and 1 or chlorhexidine videos. Videos using chlorhexidine were dated from 2014-2015, videos using isopropyl alcohol from after 2012 and all videos using a sterile drape were from after 2012. Videos using betadine were observed to be newly uploaded videos. Neuraxial anesthesia was performed in the sitting position in 26, side position in 10 and was not mentioned in 4 videos.

When IRR was evaluated, kappa score was between 0.61-0.80 in 7 videos (significant agreement), 0.41-0.60 in 31 videos (most part agreement) and 0.21-0.40 in 2 (moderate agreement) videos. The highest and lowest Kappa score was 0.69 ± 0.07 and 0.37 ± 0.09 respectively. IRR was generally high for all videos.

Discussion

The results of our study have shown that while there is numerous videos on spinal, epidural and combines anesthesia on video sharing website YouTube, more than half of these videos are low quality with relation to procedure technique, and nearly completely inadequate for patient information purposes.

Social media has gained popularity in all aspects of life as well as medicine. There are many studies that have evaluated YouTube videos for their quality for being used to give patient information and for improving skill in medical education.1-3,8,11 With regard to anesthesia, we are aware of only one study by Rössler et al.17 that evaluated videos uploaded before and including 2009. In this study, 16 spinal anesthesia and 22 lumbar puncture videos were evaluated and the videos' quality was found to be low and the authors reported that and some aseptic techniques that could be considered dangerous were used. We also found that video quality was generally poor in our study. Appropriate sterilization techniques were only defined or demonstrated in around 45% of videos. 20% of videos were classified as being extremely poor quality. On the other hand, more recently uploaded videos were found to better adhere to asepsis techniques.

There are many recently published studies comparing the use isopropyl alcohol and/or chlorhexidine vs. betadine for skin preparation.26-29 These studies have also reported an increase in the use of isopropyl alcohol and/or chlorhexidine in recent years.

Several studies have actually found that both the quality of medical procedures and their educational value are low in videos found on YouTube.1,3,8,30 Some studies, apart from noting the low quality of videos, have also strongly suggested that some videos contain misinformation that could lead to negative outcomes.31-34 Several reports have stated that videos uploaded by health professionals or academic institutes have higher quality when compared to those uploaded by individuals, and that these videos could be beneficial for the viewing of patients.2,35,36 In our study we found the quality of videos generally low and their usefulness for patient information extremely insufficient. Many videos were found to be loaded multiple times. Videos prepared by regional anesthesia societies, academic institutes or hospitals were found to have higher educational quality and better value for patient information and these videos scored higher in both questionnaires. However, we found no correlation between views/month and the quality of videos. Some studies that evaluated online videos for their value in developing medical skills also found that the quality of video correlated with the aim of the video and whether it was uploaded by an institution. Videos uploaded by professional institutions were of higher educational quality than those uploaded by individuals.7,18,37,38 60% of videos included in our study were evaluated as being aimed at medical education or healthcare professionals. Considering that many videos are in fact uploaded for educational purposes and not for patient information, a close adherence to appropriate guidelines will be useful for increasing the quality of these videos.

When evaluating the quality of the procedure we found that the quality of defining the aim of the video and demonstrating anatomical points was high. However, no attention was shown to complications, contraindications, the demonstration of the importance of appropriate monitorization and the provision of step-by-step information to the patient. Appropriate monitorization was demonstration in very few number of videos. Some videos demonstrated immediate administration of medication after entrance of spinal space, before awaiting the flow of cerebrospinal fluid. In a few videos, no care was taken for appropriate sterilization procedures. We believe that such videos are harmful if they are used for educational or skill development purposes. There were very few videos classified as very high quality, further demonstrating the need for standardization and higher quality videos especially for educational purposes.

There was no correlation between the quality of video and upload time, views/video length ratio or the type of neuraxial anesthesia in the video. Previous studies have evaluated correlation between the number of views and video quality.2,13,17 We did not find it logical to use views as an indicator of quality, as there will be a difference in views for older videos vs. newer ones. Instead, we preferred to use views/months since upload as an indicator. Views/months since upload did not correlate with video quality.

Our study has some limitations. We did not search for videos using keywords such as "spinal block", "neuraxial anesthesia", and "combined spinoepidural". These keywords may have revealed further videos. We only included English language videos and did not include videos in other languages. This study could have been designed so that non healthcare related individuals could evaluate each video according to its patient information quality and medical students for its educational value. All evaluators of Q1 and Q2 were healthcare professionals which may have led to a bias due to high expectations regarding video quality. Unfortunately there are no previously validated questionnaires that we could have used for this study. We, therefore, produced our own questioner, which we hope can be used in future studies. Our study evaluates the quality of previously uploaded videos. Future uploads may change our findings. Also, we chose to evaluate the first 60 videos for our search terms. This was a decision based on logical number a YouTube user would search for, not on any statistical calculation. Although this may be considered a limitation, this method has been used in similar studies previously.1 We would like to have included video analytics such as average view duration, traffic sources and devices to our analysis. However, this information is not available via YouTube's website.

Conclusion

Although healthcare professionals and patients are turning video sharing sites such as YouTube for health-related information or education, the quality of the majority of videos regarding spinal anesthesia, epidural anesthesia or combined spinal epidural anesthesia is not suitable for these purposes. Videos should be prepared in adherence to available and up-to-date guidelines taking into consideration appropriate step-by-step explanation of each procedure, patient safety and frequently asked questions. Although lacking in many aspects, we recommend that videos produced by institutes should be viewed for educational or informational purposes, until higher quality videos are produced.

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Received: March 4, 2016; Accepted: August 16, 2016

* Corresponding author. E-mail:serkantulgar.md@gmail.com (S. Tulgar).

Conflicts of interest

The authors declare no conflicts of interest.

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