title: Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture.
abstract: 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.
authors: Columbia University Medical Center, New York, New York; dk2592@cumc.columbia.edu.
authors: David
authors: D
authors: Kessler
authors: New York University Langone Medical Center, New York, New York;
authors: Martin
authors: M
authors: Pusic
authors: Children's Hospital of Los Angeles, Los Angeles, California;
authors: Todd P
authors: TP
authors: Chang
authors: Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York;
authors: Daniel M
authors: DM
authors: Fein
authors: Stony Brook Children's, Stony Brook, New York;
authors: Devin
authors: D
authors: Grossman
authors: Medical College of Georgia at Georgia Regents University, Augusta, Georgia;
authors: Renuka
authors: R
authors: Mehta
authors: University of Alabama at Birmingham, Birmingham, Alabama; and.
authors: Marjorie
authors: M
authors: White
authors: Yale University School of Medicine, New Haven, Connecticut.
authors: Jaewon
authors: J
authors: Jang
authors: Yale University School of Medicine, New Haven, Connecticut.
authors: Travis
authors: T
authors: Whitfill
authors: Yale University School of Medicine, New Haven, Connecticut.
authors: Marc
authors: M
authors: Auerbach
mesh_terms: D004501:Education, Medical / Q000379:methods; D004635:Emergency Medicine / Q000193:education*; D006801:Humans; D007223:Infant; D007396:Internship and Residency; D008348:Manikins; D010372:Pediatrics / Q000193:education*; D011446:Prospective Studies; D013129:Spinal Puncture / Q000592:standards*
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