BACKGROUND: Pediatric lumbar puncture (LP) is a common invasive procedure performed by physicians in training. The Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education recognize simulation as a tool for deliberate practice and standardized assessment of procedural performance. OBJECTIVE: We sought to perform a detailed review of simulated LP performance to elucidate reasons for pediatric residents' reported 26% failure rate. METHODS: Participants were enrolled in a single 30-minute session between July 2008 and January 2009. Data collected included former experience and training via questionnaire and video review of intern performance of a simulated LP on an infant model. Intern performance was assessed against a list of 10 procedural elements. Acquisition of cerebrospinal fluid (CSF), the number of elements performed on the first 2 attempts, and specific types of training/experience were analyzed for associations. RESULTS: All 32 enrolled interns endorsed receiving some previous LP training. Training on a model was infrequent (38%). Interns reported performing a median of 2 LPs prior to enrollment (interquartile range, 2-4). Seven of 31 interns (22%) had yet to perform a live LP. Eleven of 32 interns (34%; 95% confidence interval [CI], 18%-51%) acquired CSF during the first 2 simulated attempts. No specific type of prior training or experience was statistically associated with either the number of procedural elements or successful CSF acquisition (all P > .05). Interns performed a median of 7 of 10 procedural elements (interquartile range, 5.5-8). Early stylet removal was never performed. Complete removal of the stylet with all CSF checks was significantly associated with CSF acquisition (odds ratio, 9; 95% CI 0.98, 84.2). Avoidance of a spinous process upon skin entry was associated with a trend toward increased CSF acquisition (odds ratio, 3.5; 95% CI 0.76, 16.1). CONCLUSION: Despite performing many common procedural elements, pediatric interns generally lack the ability to successfully acquire CSF during a simulated infant LP. Expert performance of an infant LP likely requires complete stylet removal with each check for CSF and early spinous process avoidance. A simulated infant LP allowed assessment of intern procedural performance as well as description of elements critical to successful CSF acquisition.
BACKGROUND: Pediatric lumbar puncture (LP) is a common invasive procedure performed by physicians in training. The Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education recognize simulation as a tool for deliberate practice and standardized assessment of procedural performance. OBJECTIVE: We sought to perform a detailed review of simulated LP performance to elucidate reasons for pediatric residents' reported 26% failure rate. METHODS:Participants were enrolled in a single 30-minute session between July 2008 and January 2009. Data collected included former experience and training via questionnaire and video review of intern performance of a simulated LP on an infant model. Intern performance was assessed against a list of 10 procedural elements. Acquisition of cerebrospinal fluid (CSF), the number of elements performed on the first 2 attempts, and specific types of training/experience were analyzed for associations. RESULTS: All 32 enrolled interns endorsed receiving some previous LP training. Training on a model was infrequent (38%). Interns reported performing a median of 2 LPs prior to enrollment (interquartile range, 2-4). Seven of 31 interns (22%) had yet to perform a live LP. Eleven of 32 interns (34%; 95% confidence interval [CI], 18%-51%) acquired CSF during the first 2 simulated attempts. No specific type of prior training or experience was statistically associated with either the number of procedural elements or successful CSF acquisition (all P > .05). Interns performed a median of 7 of 10 procedural elements (interquartile range, 5.5-8). Early stylet removal was never performed. Complete removal of the stylet with all CSF checks was significantly associated with CSF acquisition (odds ratio, 9; 95% CI 0.98, 84.2). Avoidance of a spinous process upon skin entry was associated with a trend toward increased CSF acquisition (odds ratio, 3.5; 95% CI 0.76, 16.1). CONCLUSION: Despite performing many common procedural elements, pediatric interns generally lack the ability to successfully acquire CSF during a simulated infant LP. Expert performance of an infant LP likely requires complete stylet removal with each check for CSF and early spinous process avoidance. A simulated infant LP allowed assessment of intern procedural performance as well as description of elements critical to successful CSF acquisition.
Authors: Michael S Cartwright; Patrick S Reynolds; Zasha M Rodriguez; Wendy A Breyer; Julia M Cruz Journal: Med Educ Date: 2005-04 Impact factor: 6.251
Authors: Edward H Wu; D Michael Elnicki; Eric J Alper; James E Bost; Eugene C Corbett; Mark J Fagan; Alex Mechaber; Paul E Ogden; James L Sebastian; Dario M Torre Journal: Acad Med Date: 2006-10 Impact factor: 6.893
Authors: Michael G Gaies; Shaine A Morris; Janet P Hafler; Dionne A Graham; Andrew J Capraro; Jing Zhou; Christopher P Landrigan; Thomas J Sandora Journal: Pediatrics Date: 2009-07-27 Impact factor: 7.124
Authors: Amy L Baxter; Randall G Fisher; Bonnie L Burke; Sidney S Goldblatt; Daniel J Isaacman; M Louise Lawson Journal: Pediatrics Date: 2006-03 Impact factor: 7.124