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Pediatrics. 2015 May;135(5):e1237-46. doi: 10.1542/peds.2014-1911. Epub 2015 Apr 13.

Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture.

Author information

1
Columbia University Medical Center, New York, New York; dk2592@cumc.columbia.edu.
2
New York University Langone Medical Center, New York, New York;
3
Children's Hospital of Los Angeles, Los Angeles, California;
4
Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York;
5
Stony Brook Children's, Stony Brook, New York;
6
Medical College of Georgia at Georgia Regents University, Augusta, Georgia;
7
University of Alabama at Birmingham, Birmingham, Alabama; and.
8
Yale University School of Medicine, New Haven, Connecticut.

Abstract

BACKGROUND AND OBJECTIVE:

Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns' infant lumbar puncture (LP) success.

METHODS:

This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009-2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010-2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts.

RESULTS:

A total of 436 first infant LPs were analyzed. The LP success rate in cohort A was 35% (13/37), compared with 38% (152/399) in cohort B (95% confidence interval for difference [CI diff], -15% to +18%). Cohort B exhibited greater analgesia use (68% vs 19%; 95% CI diff, 33% to 59%), early stylet removal (69% vs 54%; 95% CI diff, 0% to 32%), and lower mean number of attempts (1.4 ± 0.6 vs 2.1 ± 1.6, P < .01) compared with cohort A.

CONCLUSIONS:

Across multiple institutions, intern success rates with infant LP are poor. Despite improving process measures, adding JIPT to training bundles did not improve success rate. More research is needed on optimal instructional design strategies for infant LP.

KEYWORDS:

anatomic; checklist; child; clinical competence and standards; clinical skills; competency-based education and methods; educational measurement and methods; humans; infant; internship and residency methods; manikins; medical education methods; models; outcome assessment (health care); patient simulation; pediatrics education; practice (psychology); prospective studies; spinal puncture

PMID:
25869377
DOI:
10.1542/peds.2014-1911
[Indexed for MEDLINE]
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