Pavan Zaveri

Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine.

Acquisition of competency in procedural skills is a fundamental goal of medical training. In this Perspective, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine. The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to prove competency prior to performing the procedure on a patient (Prove). Once competency is demonstrated on a simulator, the trainee is allowed to perform the procedure on patients with direct supervision, until he or she can be entrusted to perform the procedure independently (Do). Maintenance of the skill is ensured through continued clinical practice, supplemented by simulation-based training as needed (Maintain). Evidence in support of each component of the framework is presented. Implementation of the proposed framework presents a paradigm shift in procedural skill training. However, the authors believe that adoption of the framework will improve procedural skill training and patient safety.

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

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.

Script concordance testing: Assessing residents' clinical decision-making skills for infant lumbar punctures

Purpose Residents must learn which infants require a lumbar puncture (LP), a clinical decision-making skill (CDMS) difficult to evaluate because of considerable practice variation. The authors created an assessment model of the CDMS to determine when an LP is indicated, taking practice variation into account. The objective was to detect whether script concordance testing (SCT) could measure CDMS competency among residents for performing infant LPs. Method In 2011, using a modified Delphi technique, an expert panel of 14 attending physicians constructed 15 case vignettes (each with 2 to 4 SCT questions) that represented various infant LP scenarios. The authors distributed the vignettes to residents at 10 academic pediatric centers within the International Simulation in Pediatric Innovation, Research, and Education Network. They compared SCT scores among residents of different postgraduate years (PGYs), specialties, training in adult medicine, LP experience, and practice within an endemic Lyme disease area. Results Of 730 eligible residents, 102 completed 47 SCT questions. They could earn a maximum score of 47. Median SCT scores were significantly higher in PGY-3s compared with PGY-1s (difference: 3.0; 95% confidence interval [CI] 1.0–4.9; effect size d = 0.87). Scores also increased with increasing LP experience (difference: 3.3; 95% CI 1.1–5.5) and with adult medicine training (difference: 2.9; 95% CI 0.6–5.0). Residents in Lyme-endemic areas tended to perform more LPs than those in nonendemic areas. Conclusions SCT questions may be useful as an assessment tool to determine CDMS competency among residents for performing infant LPs.

The Correlation of Workplace Simulation-Based Assessments With Interns' Infant Lumbar Puncture Success: A Prospective, Multicenter, Observational Study.

Introduction Little data are available to guide supervisors’ decisions regarding when trainees are prepared to safely perform their first procedure on a patient. We aimed to describe the correlation of simulation-based assessments, in the workplace, with interns’ first clinical infant lumbar puncture (ILP) success. Methods This is a prospective, observational subcomponent of a larger study of incoming interns at 33 academic medical centers (July 2010 to June 2012) assessing the impact of just-in-time training. When an intern’s patient required an ILP, a just-in-time simulation-based skills refresher was conducted with his or her supervisor. At the end of the refresher, supervisors assessed interns’ ILP skills on a simulator in the workplace before clinical performance using a four point anchored scale. The primary outcome was the correlation of supervisors’ assessment and interns’ procedural success. The number needed to assess for this instrument (1 / absolute risk reduction) was calculated. Results A total of 1600 interns were eligible to participate, and 1215 were enrolled. A total of 297 completed an assessment and a subsequent clinical ILP. Success rates for each scale rating were 29% (18/63) for novice, 39% (51/130) for beginner, 55% (46/83) for competent, and 43% (9/21) for proficient. The correlation coefficient was 0.161 (95% confidence interval, 0.057–0.265), indicating a weak correlation between supervisor rating and success. Success rate was 53% for the ratings of competent or proficient compared with 35% for the ratings of novice or beginner. Using the global rating scale for the summative assessment to determine procedural readiness could lead to 1 fewer patient experiencing a failed ILP for every 6 interns tested (6.2; 95% confidence interval, 4.0–8.5). Conclusions A simulation-based assessment of interns conducted in the workplace before their first ILP has some value in predicting clinical ILP success.

Overweight children: Are they at increased risk for severe injury in motor vehicle collisions?

BACKGROUND Obesity is an epidemic in the United States. The relationship between traumatic injury and obesity in children is not well-studied. We hypothesized that overweight children suffer more severe injuries, different distributions of injuries and improper use of restraints in motor vehicle collisions. METHODS We conducted a secondary analysis of the CIREN database of motor vehicle collisions of subjects 2-17 years old. Overweight was defined as a BMI percentile for age >85%. Significant injury was an Injury Severity Score (ISS) >15 or an Abbreviated Injury Scale (AIS) score greater than one. Further analysis looked at injuries classified as head, trunk, or extremities and appropriateness of restraints. Odds ratios compared the overweight to lean groups. RESULTS 335 subjects met inclusion criteria with 35.5% of cases being overweight. For significant injury, overweight cases had an odds ratio of 1.2 [95% CI: 0.8-1.9]. Analysis by AIS for overall significant injury and to specific body regions also did not show any significant associations. Overweight versus lean subjects had an odds ratio of 1.3 [95% CI: 0.8-2.1] for improper use of restraints. CONCLUSIONS We found no significant relationship between pediatric injury severity, distribution of injuries, or restraint use and being overweight. Limitations of this study were the small sample size in this database and the large number of unrestrained subjects.

Virtual Reality for Pediatric Sedation: A Randomized Controlled Trial Using Simulation.

Introduction: Team training for procedural sedation for pediatric residents has traditionally consisted of didactic presentations and simulated scenarios using high-fidelity mannequins. We assessed the effectiveness of a virtual reality module in teaching preparation for and management of sedation for procedures. Methods: After developing a virtual reality environment in Second Life® (Linden Lab, San Francisco, CA) where providers perform and recover patients from procedural sedation, we conducted a randomized controlled trial to assess the effectiveness of the virtual reality module versus a traditional web-based educational module. A 20 question pre- and post-test was administered to assess knowledge change. All subjects participated in a simulated pediatric procedural sedation scenario that was video recorded for review and assessed using a 32-point checklist. A brief survey elicited feedback on the virtual reality module and the simulation scenario. Results: The median score on the assessment checklist was 75% for the intervention group and 70% for the control group (P = 0.32). For the knowledge tests, there was no statistically significant difference between the groups (P = 0.14). Users had excellent reviews of the virtual reality module and reported that the module added to their education. Conclusions: Pediatric residents performed similarly in simulation and on a knowledge test after a virtual reality module compared with a traditional web-based module on procedural sedation. Although users enjoyed the virtual reality experience, these results question the value virtual reality adds in improving the performance of trainees. Further inquiry is needed into how virtual reality provides true value in simulation-based education.

Essentials of Pediatric Emergency Medicine Fellowship: Part 4: Beyond Clinical Education.

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the skills beyond clinical training required of pediatric emergency medicine physicians including teaching, leadership, teamwork, and communication.

Essentials of Pediatric Emergency Medicine Fellowship: Part 1: An Overview.

This article is the first in a 7-part series (Table 1) that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated on program completion. This overview article provides a framework for the series.

Creating Consensus Educational Goals for Pediatric Sepsis via Multicenter Modified Delphi

Clinical care of pediatric sepsis depends on early recognition and basic initial steps and thus focused educational materials for providers in these early phases of care are needed. The authors sought to identify educational goals and establish a framework for those materials.

Essentials of Pediatric Emergency Medicine Fellowship: Part 6: Program Administration.

This article is the sixth in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article provides a broad overview of administering and supervising a PEM fellowship program. It explores 3 topics: the principles of program administration, committee management, and recommendations for minimum time allocated for PEM fellowship program directors to administer their programs.