IPSSW Impact on LP Success

S

Impact of a Simulation-Based Just-In-Time Refresher Training for Interns on Their Clinical

Success Rate with Infant Lumbar Puncture

Daniel Fein, Todd Chang, Dewesh Agrawal, Jennifer Reid, Joshua Rocker, Martin Pusic, Laura Haubner, Marc

Auerbach

on behalf of the POISE Investigators

David Kessler, MD, MScAssistant Professor of Clinical Pediatrics

Director of Clinical OperationsDivision of Pediatric Emergency Medicine

Co-director of the POISE research network

Conflict of Interest

S On behalf of myself (and any co-presenters of the papers I am responsible for), I declare to my knowledge, there are no conflicts of interest that would prevent me from presenting this work at the IPSSW2011.

S The POISE Network is funded by a grant by

Background

• Simulation is effective for skills training

• The ideal timing and duration of training needed to

make a clinical impact are largely unknown

Background

• Simulation based mastery education (SBME) is a method of training to a predefined endpoint

Background

• Simulation based mastery education (SBME) is a method of training to a predefined endpoint

• Metanalysis of SBME using deliberate practice vstraditional clinical education

• Inclusion: SBME intervention, comparison group, skill outcome

• 3742 articles screened, 14 included

• Effect size: 0.71 (95% confidence interval, 0.65–0.76; P .001)

McGaghie W, Issenberg B, Cohen E, Barsuk J, Wayne D. Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of The Evidence. Acad Med. 2011;86:706–711

Background

• Just-in-time (JIT) training is a refresher session that occurs temporally close to the actual clinical encounter / skill being performed

Background

• Just-in-time (JIT) training is a refresher session that occurs temporally close to the actual clinical encounter / skill being performed

• Rolling refreshers for CPR

• Practice compressions on simulator (to mastery)

• High frequency >2 refreshers per month

• Low frequency <2 refreshers per month

• High frequency group achieved mastery faster

Nilesa D, Sutton R, Donoghuea A, Kalsic M, Roberts K, Boyled L, Nishisakia A, Arbogaste K, Helfaerb M, Nadkarni V. “Rolling

Refreshers”: A novel approach to maintain CPR psychomotor skill competence. Resuscitation 80 (2009) 909–912

Objectives

S To compare the impact of 2 different training

strategies on clinical success rates with the infant

lumbar puncture (LP) procedure.

1. A single simulation based mastery education session using

coached deliberate practice (SBME)

2. SBME plus just-in-time (JIT) refreshers on clinical success

rates with the infant lumbar puncture (LP) procedure.

Methods

S Design: Multicenter prospective study with historical

control group

S Setting: 21 academic training centers

S Population: Pediatric interns

Methods

SBME

Orientation

Time = 0

2009-

2010

cohort

2010-

2011

cohort

SBME

Methods

SBME

Orientation

Time = 0

2009-

2010

cohort

2010-

2011

cohort

SBME

Methods

SBME

Orientation

Time = 0

JIT

LP Clinical encounter #12009-

2010

cohort

2010-

2011

cohort

SBMELP Clinical encounter #1

Methods

SBME

Orientation

Time = 0

JIT

LP Clinical encounter #1

JIT

2009-

2010

cohort

0 to 6 months

2010-

2011

cohort

SBME*

LP#2,3…

LP#2,3…LP Clinical encounter #1

Methods

SBME

Orientation

Time = 0

JIT


JIT

2009-

2010

cohort

0 to 6 months

2010-

2011

cohort

SBME*

LP#2,3…


Methods

SBME

Orientation

Time = 0

JIT


JIT

2009-

2010

cohort

0 to 6 months

2010-

2011

cohort

SBME*

LP#2,3…


Primary outcome: atraumatic

infant LP (<1000 rbcs/hpf)

Results

104 interns enrolled 51 interns report 102 LPs2009-2010

(SBME)

Results

501 interns enrolled

104 interns enrolled

161 interns report 228

LPs

51 interns report 102 LPs

2010-2011

(SBME + JIT)

2009-2010

(SBME)

Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SBME SBME+JIT

Intern Clinical Success Rate

with Infant Lumbar Puncture

45%(102/228)

45%(46/102)

2009 cohort 2010 cohort

(95% CI for difference: -0.1 to 0.1)

Results

Limitations

• Historical controls

• Reporting bias

• Novice learners

Conclusions

S SBME plus subsequent JIT is not superior to SBME alone in improving interns’ LP success rates

Future directions

• Bedside competency assessment as predictor of success

• Increased opportunity for self-directed practice

Acknowledgements

POISE Study Investigators:

S Akron Children’s Hospital (Holder), AI Dupont (Stryjewski), Cardinal Glennon SLU (Gerard, Scalzo), Children’s Hospital of Boston (Kothari), Children's Hospital of Los Angeles (Keeler, Mody, Ostrom), Children’s Hospital at Montefiore (Avner, Fein), Children's Hospital of New York Presbyterian (Kessler, Pusic, Tilt), Children's Hospital of Pittsburgh (Zuckerbraun, McAninch), Children’s National Medical Center (Zaveri, Chang, Birch, Agrawal, Seelbach), Cohen Children's Medical Center of New York (Rocker, Israel, Bruckner, Sherman), Emory University (Hebbar), Inova-Fairfax (Kou, D'Andrade, Hwang), University of Iowa Children's Hospital (Lindower, Rabe), Mayo Clinic (Arteaga, Matthews), Medical College of Georgia (Mehta, Sharma, Lane), Mount Sinai Medical Center (Paul, Strother), Nationwide Childrens Hospital (Scherzer), NYU Medical Center (Ching, Torch, Foltin, Cleary), Robert Wood Johnson (Pratt), Seattle Children’s Hospital (Cico, Klein, Reid), Tulane Hospital for Children (Keane, Krantz, Petrescu, Washko), University of South Florida (Haubner, Nations), University of Texas Southwestern (Srivastava), Weill Cornell (Shah, Weinberg, O'Malley), Yale University (Auerbach, Kamdar, Duran)