• Pediatrics · May 2015

    Multicenter Study

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

    • David Kessler, Martin Pusic, Todd P Chang, Daniel M Fein, Devin Grossman, Renuka Mehta, Marjorie White, Jaewon Jang, Travis Whitfill, Marc Auerbach, and INSPIRE LP investigators.
    • Columbia University Medical Center, New York, New York; dk2592@cumc.columbia.edu.
    • Pediatrics. 2015 May 1;135(5):e1237-46.

    Background And ObjectiveSimulation-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.MethodsThis 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.ResultsA 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.ConclusionsAcross 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.Copyright © 2015 by the American Academy of Pediatrics.

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