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KidSIM Journal Club
Presenter: Amani Azizalrahman
June 19th , 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. 2011 Aug;6(4):197-203
• Introduction of the study
- Background, Method, Result, Discussion
• Critical Appraisal
– Was the result valid?
– What was the result? (clinical significant vs. statistical
– Is the result applicable to our practice?
• 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
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
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
an audiovisual presentation
on the LP procedure
an audiovisual presentation
on the LP procedure
No intervention
hands-on simulation-based
coached deliberate practice
training session.
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
– 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
Clinical Skills
Clinical Skills
Simulator Skills
Simulator Skills
Secondary Outcomes
– Scores on the 6-item knowledge quiz:
- Baseline: (5 Control vs 4.9 Intervention)
- After 6 - 8 months: (5.5 control vs. 5.5
– Knowledge (5.4 Control vs 5.2 Intervention)
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)
– 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
Educational strategies:
- Deliberate practice
- Action-oriented coaching
- Mastery training on the simulator
- Clinical performance was measured by self-report
- The lack of true blinding of subjects to the interventions
- Underreporting at the 6-months follow-up
- 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
• Recommendation:
Future studies with large sample size
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?
– Is the problem studied one that is common in practice ?
– Will this information, if true, require you to change your
current practice?
Was the result valid?
– Were the participants in all groups followed up and
data collected in the same way?
– How are the results presented and what is the main
Intervention group performed better than the control
group, by tables
Was the result valid?
– Are the results clinically as well as statistically
– was the power of the study adequate?
Thank you