Impact of just-in-time and just-in-place simulation on intern success with infant lumbar puncture

David Kessler, Martin Pusic, Todd P. Chang, Daniel M. Fein, Devin Grossman, Renuka Mehta, Marjorie White, Jaewon Jang, Travis Whitfill, Marc Auerbach, Michael Holder, Glenn R. Stryjewski, Kathleen Ostrom, Lara Kothari, Pavan Zaveri, Berry Seelbach, Dewesh Agrawal, Joshua Rocker, Kiran Hebbar, Maybelle KouJulie Lindower, Glenda Rabe, Audrey Paul, Christopher Strother, Eric Weinberg, Nikhil Shah, Kevin Ching, Kelly Cleary, Noel Zuckerbraun, Brett McAninch, Amanda Pratt, Jennifer Reid, Steve Cico, James Gerard, Matei Petrescu, Laura Haubner, Geetanjali Srivastava, Denis Oriot, Grace Arteaga, Daniel Lemke, Wendy Van Ittersum, Alisa McQueen, Stephen M. Blumberg, Sandra Arnold, Peggy O'Cain, Melissa Cercone

Research output: Contribution to journalArticlepeer-review

34 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)e1237-e1246
Issue number5
StatePublished - May 1 2015

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health


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