KidSIM Journal Club Presenter: Amani Azizalrahman June 19 th, 2014

A Randomized Trial of Simulation-Based Deliberate Practice for Infant Lumbar Puncture Skills David O. Kessler, Marc Auerbach, Martin Pusic, Michael G. Tunik,Jessica C. Foltin Simul Healthc Aug;6(4): Article

Outline Introduction of the study - Background, Method, Result, Discussion Critical Appraisal –Was the result valid? –What was the result? (clinical significant vs. statistical significant? – Is the result applicable to our practice? (generalizability) Discussion

Study Introduction Background –Pediatric skills training has traditionally employed the apprenticeship model of “see one, do one, teach one” at the patients bedside –Simulation-based interventions are well received by trainees and faculty –No systematic evaluation for their effect on pediatric patient outcomes Issenberg et al. Med Teach 2005;27:10 –28 Scalese et al. J Gen Int Med 2007;23:46–49

Study Introduction Deliberate practice is a key feature of simulation-based interventions for learning complex procedures A study by Conroy reported that interns who participated in deliberate practice on adult LP task trainers with focused feedback developed high levels of skill and retained these skills on the simulator at 3 to 6 months Sim Healthcare 2010;5:133–138

Study Introduction Hypothesis Mastery training with coached deliberate practice on an infant LP simulator combined with an audiovisual training (AV) will improve clinical success rates with the procedure

Study Design Design/ Methods –Residents were randomized within class year using a random number generator to participate in either intervention or control groups. –In an urban tertiary care Department of Pediatrics. –The local institutional review board approved this study. –Informed consent at the start of the year was obtained.

PICO Question P: pediatric residents I : watch audiovisual presentation on the LP procedure, hands-on simulation-based coached deliberate practice training session C: watch audiovisual presentation on the LP procedure O: improvement in pediatrics resident skills and confidence during LP for infant

Study Design Baseline Assessment - questionnaires were completed to assess: (1) Prior training (2) Experience with the infant LP procedure (3) Knowledge (using a 6-item quiz) (4) Confidence with the procedure (using a 4-point Likert scale)

Study Design Baseline Assessment –Individuals from both groups were then videotaped performing an LP on a Laerdal Baby Stap neonatal task trainer –(OSCE) was scored by the instructors on the day of training and later using video review by an author blinded to group assignment, using a 15-item checklist of critical steps developed for this study

Study Design Training ControlIntervention an audiovisual presentation on the LP procedure No interventionhands-on simulation-based coached deliberate practice training session. questionnaires

Study Design Clinical Outcome - Participants were instructed to provide data at the time of their first LP performed on an infant (less than 12 months of age) - Online data entry tool - The participants answer questions measuring confidence, attitudes about their LP training experience after they had performed a clinical patient LP

Study Design Data collected included: –Whether cerebrospinal fluid (CSF) was obtained or not, number of attempts –Cell counts, fluid appearance –Age of the patient –Clinical environment where the procedure was performed –Prior attempt was made by another physician or not

Study Design Simulator Outcome(OSCE) - After 6 to 8 months - OSCE using simulator - Assessments of knowledge and confidence - Control group received the coached experiential simulator training

Results

Clinical Skills

Results Clinical Skills

Results Simulator Skills

Results Simulator Skills

Results Secondary Outcomes –Scores on the 6-item knowledge quiz: - Baseline: (5 Control vs 4.9 Intervention) - After months: (5.5 control vs. 5.5 intervention) – Knowledge (5.4 Control vs 5.2 Intervention)

Results Secondary Outcomes –Confidence : - Baseline(2.8 Control vs. 2.7 Intervention) - After training (3.2 Control vs. 3.4 Intervention) –Confidence (after 6-8 months) -(3.2 Control vs. 3.4 Intervention )

Discussion – The results support the authors hypothesis that simulation-based deliberate practice training improves LP procedural skills among pediatric residents –This study demonstrate the translation of a simulation skills training into improvements in providers’ clinical performance in pediatric

Discussion Educational strategies: - Deliberate practice - Action-oriented coaching - Mastery training on the simulator

Discussion Limitations: -Clinical performance was measured by self-report -The lack of true blinding of subjects to the interventions - Underreporting at the 6-months follow-up

Discussion Limitations: - The OSCE checklist was not validated - Teaching intervention was in a single training session - Sample size did not provide adequate power to analyze all subgroups and confounders

Discussion Recommendation: Future studies with large sample size

Conclusions Simulation-based deliberate practice on an infant LP simulator after an audiovisual didactic improves the odds of obtaining CSF with the next clinical infant LP performed when compared with AV alone, independent of other factors

Was the result valid?  Determine Relevance –Did the authors study an outcome that patients would care about? Yes –Is the problem studied one that is common in practice ? Yes –Will this information, if true, require you to change your current practice? Yes

Was the result valid?  Study design: –Randomization -Using a random number generator -Allocation concealment mechanism not mentioned –Blindness -During the (OSCE) instructors where not blinded -Author who reviewed the video later was blinded to group assignment

Was the result valid? –Were the participants in all groups followed up and data collected in the same way? Yes –How are the results presented and what is the main result? Intervention group performed better than the control group, by tables

Was the result valid? –Are the results clinically as well as statistically significant? Yes – was the power of the study adequate? Yes

Thank you