Improving Emergency Medicine Resident Pediatric Lumbar Puncture Procedural Performance through a Brief Just-In-Time Video Intervention

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McGuire, Alexander S. Finch, Jenna M. Thomas, Octavio Lazaro, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4152752/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jun, 2024 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract BACKGROUND Emergency medicine (EM) trainee comfort level with lumbar puncture (LP) has decreased over time due to changing practice guidelines, particularly amongst pediatric patients. We implemented a “just in time” (JIT) brief educational video based on a validated LP evaluation checklist to improve trainee efficiency and competence in LP performance. METHODS Our experimental study took place January-June 2022 within a large, academic Midwestern emergency department (ED) with an established 3-year EM residency program. All 9 interns performed a timed diagnostic LP on an infant LP model in January, scored according to a previously validated LP Performance Scoring Checklist. In June, interns repeated the timed LP procedure directly after watching a brief educational video based on major checklist steps. The study was deemed exempt by the Institutional Review Board. RESULTS All interns completed both assessments. At baseline, interns had logged performance of median 2 (IQR 0–5) LPs and spent 12.9 (10.3–14.4) minutes performing the procedure. Post-intervention, interns had logged an additional median 2 (0–5) LPs and completed the procedure faster with an average time of 10.3 (9.7–11.3) minutes (p = 0.004). A median of 5 ( 4 – 7 ) major steps were missed at baseline, compared to 1 ( 1 – 2 ) at time of post-intervention assessment (p = 0.015). CONCLUSION Development of a brief educational video improved efficiency and competency amongst our intern class in performing an infant LP when viewed Just-In-Time. Similar efforts may improve education and performance of other rare (or decreasing in frequency) procedures within EM training. Future research with other procedures, larger learner cohorts, and comparing JIT approaches will be necessary to determine whether JIT videos based on validated assessment checklists are truly “best practice”. Formal evaluation of the effect of similar “standardized” videos on cognitive load of learners and supervisors is also an important avenue of future research. lumbar puncture procedural efficiency resident education emergency medicine pediatric lumbar puncture pediatric procedure medical education just-in-time education Figures Figure 1 BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) requires emergency medicine (EM) residencies to certify competence of trainees in procedures viewed as essential to the independent practice of EM. 1 Lumbar puncture (LP) is one of these procedures as it remains a mainstay of the diagnostic evaluation for patients with suspected central nervous system disorders due to infection, autoimmunity, and hemorrhage, and provides diagnostic and therapeutic benefit in cases such as idiopathic intracranial hypertension. 2 Importance Despite its importance, trainee comfort level with the LP procedure has decreased over time due to changing practice guidelines, particularly amongst pediatric patients. 3 Across children’s hospitals nationwide, performance of LPs has decreased by 37% over the past decade, likely due to widespread vaccination and implementation of risk stratification algorithms that have changed the way febrile infants are managed in the emergency department (ED). 4 With decreasing clinical experience during training, average attending experience with the procedure is also expected to decrease, making effective standardized training interventions ever more important in competency-based medical education. Goals of this investigation We sought to improve competency at this increasingly rare procedure in our residency through a brief educational video, focusing initial efforts on our post-graduate year (PGY)-1 intern class. METHODS Study Design and Setting This experimental study took place January—June 2022 within a large, academic Midwestern ED. The ED has an established 3-year EM residency with 9 residents per year and features both adult and pediatric care areas. A total of 32 LPs were performed in the ED on pediatric (< 18 years of age) patients between 7/1/2021 and 6/30/2022, 25 (78.1%) on patients < 1 year of age. EM residents performed 17 (53.1%) of the total pediatric LPs, including 13 (52.0%) of the infant LPs. Selection of Participants In January, all 9 EM interns were invited to participate in a “procedural project,” with the type of procedure blinded to participants. Participants were compensated with a $ 10 hospital cafeteria voucher, with an additional $ 5 bonus voucher offered if the entire class participated. The same compensation was offered at the time of post-intervention assessment in June. Informed consent of participants was obtained at time of assessment scheduling and re-obtained verbally at time of assessment performance. The study was reviewed by the Mayo Clinic Institutional Review Board and deemed exempt. Baseline Measurement At their individual baseline performance assessment, participants were provided the department’s standard CareFusion Pediatric/Infant LP Kit and asked to perform a timed diagnostic LP (including obtaining an opening pressure) on an infant LP model (Pediatric LP Simulator II Model). 5 Cerebrospinal fluid (CSF) was simulated by a hanging liter bag of saline connected to a rubber tube concealed within the model, allowing for flow with successful dura puncture (Fig. 1 ). This simulated CSF flow, along with a tactile “pop” sensation with needle entry into the tube, allowed for recognition of penetration of the dura. Non-sheer tape was replaced over the spine before each trainee to obscure prior puncture marks. Performance was scored according to a previously validated LP Performance Scoring Checklist as described in Lammers et al. 3 A PGY-3 EM chief resident (S.M.) and EM attending physician (A.F.) observed and scored the assessments to assess competence (critical actions correctly performed) utilizing the checklist’s 26 major steps (Table 1 ), defined by Lammers et al. as “critical steps that could cause a complication or procedural failure if omitted, performed incorrectly, or performed out of sequence.” 3 Lammers’ 44 minor steps were omitted as some were optional variances in technique. 3 Participants were encouraged to verbalize their actions and were prompted, when necessary, to clarify details associated with a step (e.g. which bony landmark they were palpating and to which interspace level it corresponded). Timing began after instructions were given and ended after a bandage was placed and caps screwed onto all collection tubes. Participants received no feedback during or after the procedure and did not view the checklist being utilized. Table 1 Completion of Major Steps (from previously published validated Performance Scoring Checklist to assess Competence in Lumbar Punctures 3 ) at Baseline Procedural Performance Assessment compared to Post-Intervention Procedural Performance Assessment (N = 9) † Time to completion (minutes) Validation Item/ Major Step Description Step Performed Baseline 12.9 (10.3, 14.4) Post-Intervention 10.3 (9.7, 11.3) p-value 0.004 1.1 Place the patient in a lateral decubitus position or upright position. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 1.2 Check the spine for maximum flexion. No Yes 8 (89%) 1 (11%) 6 (67%) 3 (33%) 0.35 2.1 Identify the L4-L5 interspace at the point intersecting the iliac crest line with the body midline. No Yes 3 (33%) 6 (67%) 1 (11%) 8 (89%) 0.35 3.1 Put on sterile gloves without contamination. No Yes 1 (11%) 8 (89%) 0 (0%) 9 (100%) 0.99 4.1 Place sponge stick into Betadine. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 4.2 Wipe the skin in a circular motion from the target area to about a 10 cm radius. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 5.1 Insert the needle into the subcutaneous tissue. No Yes 2 (22%) 7 (78%) 0 (0%) 9 (100%) 0.35 5.2 Inject 1–3 cc of anesthetic solution. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 6.1 Place the needle in the center of the interspace. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 6.2 Angle the needle toward the umbilicus. No Yes 2 (22%) 7 (78%) 0 (0%) 9 (100%) 0.35 7.1 Advance the needle into the skin slowly and smoothly. No Yes 5 (56%) 4 (44%) 0 (0%) 9 (100%) 0.037 7.2 Once the needle passes through the subcutaneous tissue, turn the bevel of the needle laterally. No Yes 0 (0%) 9 (100%) 3 (33%) 6 (67%) 0.15 7.3 Advance the needle. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 7.4 Remove the stylet and check for fluid. No Yes 3 (33%) 6 (67%) 0 (0%) 9 (100%) 0.15 7.5 Reinsert the stylet. No Yes N/A 1 (11%) 8 (89%) 0 (0%) 0 (0%) 7 (78%) 2 (22%) 0.99 7.6 Advance the needle further until a pop is felt, an obstruction prevents further movement or the patient reports parasthesias or radicular pain. No Yes N/A 3 (33%) 6 (67%) 0 (0%) 1 (11%) 5 (56%) 3 (33%) 0.60 7.7 Remove the stylet and check for fluid. No Yes N/A 1 (11%) 8 (89%) 0 (0%) 0 (0%) 6 (67%) 3 (33%) 0.99 7.8 If there is an obstruction and no fluid or if there are parasthesias and no fluid or if there is bright red blood, withdraw the needle and repeat the above 2 steps, reposition the needle or use a different interspace. No Yes N/A 3 (33%) 3 (33%) 3 (33%) 0 (0%) 2 (22%) 7 (78%) 0.46 8.1 Attach the manometer/stopcock to the needle hub. No Yes 2 (22%) 7 (78%) 1 (11%) 8 (89%) 0.77 8.2 Turn the stopcock valve until the dial is parallel with the manometer. No Yes 5 (56%) 4 (44%) 1 (11%) 8 (89%) 0.072 8.3 Allow the fluid to fill the manometer until the meniscus stops rising. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 8.4 Measure the CSF opening pressure correctly. No Yes 0 (0.0%) 9 (100%) 0 (0.0%) 9 (100%) --- 9.1 Place the first tube under the stopcock. No Yes 5 (56%) 4 (44%) 1 (11%) 8 (89%) 0.072 9.2 Collect 1 cc of CSF. No Yes 3 (33%) 6 (67%) 1 (11%) 8 (89%) 0.35 9.3 Screw the cap on the first tube with one hand, and place the tube upright in the slot on the tray. No Yes 3 (33%) 6 (67%) 0 (0%) 9 (100%) 0.15 10.1 Withdraw the needle. No Yes 2 (22%) 7 (78%) 1 (11%) 8 (89%) 0.99 † Items marked as “N/A” (Not Applicable) indicate the participant successfully punctured the dura with CSF flow observed by step 7.4, thereby not requiring subsequent steps 7.5–7.8. P-values comparing baseline and post-intervention assessments do not include “N/A” responses. Intervention S.M. and O.L. designed and filmed a brief (4.25 minutes) instructional LP procedure video 6 that demonstrated the checklist's major steps (Table 1 ) . The video was distributed via email in March to all trainees rotating through the ED and uploaded onto the department’s Intranet Education webpage. Post-Intervention Measurement At the time of post-intervention assessment, participants were asked whether they had reviewed or utilized the video. Regardless of response, all participants were shown the video before proceeding with the same procedural assessment on the same infant LP model as performed at baseline, described above. This was done to ensure that the video was used as a JIT resource, as intended, rather than viewed at a time and location remote from procedural performance. The number of LPs logged by participants, as required by the residency, were pulled from the program’s graduate medical education (GME) administrative management software 7 in order to ascertain LP procedural experience at time of each assessment. Logged procedures could include those performed in the clinical and simulation settings. Data Analysis Intern performance on the LP Performance Scoring Checklist 3 was compared between baseline and post-intervention assessments using paired Fisher’s exact tests (completion of each major step) and Wilcoxon signed-rank tests (time to completion, total steps missed). RESULTS All 9 interns completed both the baseline and post-intervention performance assessments. At the time of baseline assessment, interns had logged a median 4 (IQR 0–10) LPs, with median 2 (IQR 0–5) logged as “performed” (as opposed to simulated, observed, or assisted). Median baseline time to completion of the procedure was 12.9 (10.3–14.4) minutes (Table 1 ). Post-intervention, interns had logged an additional median of 4 (0–11) LPs, including median 2 (IQR 0–5) logged as “performed” and completed the procedure faster with a median time of 10.3 (9.7–11.3) minutes (p = 0.004). Three (33.3%) of the interns reported previously reviewing the video on their own. A median of 5 ( 4 – 7 ) major steps were missed by each intern at baseline, compared to median 1 ( 1 – 2 ) major step missed at time of post-intervention assessment (p = 0.015). Interns demonstrated either continued (n = 8) or improved competency (n = 17) of all major steps post-intervention, with the exception of turning the bevel of the needle laterally (Step 7.2). Among the major steps that were completed more frequently post-intervention, the only one reaching statistical significance was 7.1, advancement of the needle into the skin slowly and smoothly (p = 0.037). DISCUSSION Innovative approaches have historically been employed to provide medical trainees exposure to infrequent, invasive, and time-sensitive procedures which they may rarely, if ever, encounter. 8–11 As the frequency of LPs performed in the clinical environment decreases, so too do trainees’ encounters with them. Not only does the ACGME require residents to cite performance of a certain number of these procedures in order to graduate, 1 GME in the United States has moved towards a competence-based approach, requiring educators collect and demonstrate measurable evidence that trainees achieve specific, predetermined outcomes. 12–13 Hidden amongst trainee data is the implication that as experience during training with a clinical procedure decreases, so too does the experience of the next generation of attending physicians who are responsible for supervising trainees. With increasing focus on managing (and measuring) cognitive load in medical education for both trainer and trainee, educational interventions which target optimization of cognitive load are expected to benefit clinical practice in both immediate and long-term settings. 14–15 By utilizing a previously validated checklist in a brief JIT video, we ensure that agreed-upon elements of procedural competence are reliably demonstrated to the trainee independent of the supervising physician’s time, attention, or skill in teaching, all of which are particularly variable in the clinical environment where other departmental and patient care priorities must be balanced. Our study demonstrates the benefit of utilizing a brief procedural video on both resident efficiency (time spent) and competence (critical actions correctly performed) in performing a LP. Given 66.7% of our cohort acknowledged watching the video for the first time at their post-assessment, our findings suggest a Just-In-Time (JIT) learning benefit, contrary to prior JIT LP studies that have demonstrated equivocal success. 16–17 Similar efforts may improve education and performance of other rare procedures within EM training. We isolated the intern class as our intervention cohort given their expected novice baseline experience and competency with the procedure, as well as the need to improve upon both during their training. It is possible that the intervention had the same beneficial or a less beneficial impact amongst more senior EM residents or trainees from other specialties. We used a six-month time period between assessments to balance adequate time for simulation skill decay against clinical encounters allowing for LP performance. Participants documented performing a median of 2 LPs (and overall completing a median of 4 LPs) during the six months between baseline and post-intervention assessments, which was similar to the six months prior to baseline assessment (median 4 LPs, performed: p = 0.81; completed: p > 0.99). This suggests that exposure to the procedure external to our study likely had minimal influence on the improvement we observed in procedural efficiency and competency after our intervention. Our study demonstrated benefit to trainee efficiency and competency after watching the video. However, only 1/3 of participants acknowledged having watched the video independently, and it is unclear to what degree attending physicians supervising these trainees utilized the video as a JIT tool as intended. Utilizing a brief video to provide JIT teaching and/or review has the benefit of cognitively offloading the supervising physician during the clinical shift, decreasing the required time away from other clinical responsibilities while being certain that all standardized evaluation (and by extension, competency) criteria have been demonstrated to the trainee by the video. Moreover, this allows a brief “refresher” of the procedure for the supervising physician if desired, particularly if they have not recently performed the procedure themselves. More effort is warranted to demonstrate the effectiveness and ease of use of similar JIT training videos to all stakeholders (trainer and trainee alike) in the future in order to encourage greater uptake. LIMITATIONS This study has several important limitations. Most salient is the small number of learners in our sample. We viewed this as a pilot to test whether a JIT video based on a validated checklist for procedural evaluation was effective in achieving increased procedural efficiency and/or competence, and feasible to design and distribute within a cohort of junior learners. Additionally, we did not independently verify trainee procedure logs, which could allow for error in entry by the performing resident. Administrative habits were thought likely to remain stable between the time of both assessments. We presented overall data of procedure logs, including number of LPs logged as having been directly performed and those logged as having been completed overall. We are unable to verify how many of these ‘completed’ LPs were actually simulated, observed, or even supervised with performance feedback. Additionally, although we did not tell participants beforehand what procedure they would be asked to perform at time of their second (post-intervention) assessment, it is possible that they correctly assumed it would again be a LP and reviewed other resources to prepare. To mitigate this, we emphasized that performance would have no bearing on a participant’s residency evaluations. Although the simulator model used was high-quality, the static nature of our model does not fully replicate performing an LP procedure on a live infant. However, given the demonstrated decrease in availability of these procedures clinically, we believe our high-fidelity simulated model serves as the best available alternative. Finally, this study was performed within one academic EM residency program in the Midwest and may not be generalizable broadly to other training programs or institutions. CONCLUSION Development of a brief educational video improved efficiency and competency amongst our intern class in performing an infant LP when viewed Just-In-Time. Similar efforts may improve education and performance of other rare (or decreasing in frequency) procedures within EM training. Future research with other procedures, larger learner cohorts, and comparing JIT approaches will be necessary to determine whether JIT videos based on validated assessment checklists are truly “best practice”. Formal evaluation of the effect of similar “standardized” videos on cognitive load of learners and supervisors is also an important avenue of future research. Declarations Ethics approval and consent: Consent was obtained by all participants. The study was reviewed by the Mayo Clinic Institutional Review Board and deemed exempt. Consent for publication: Not applicable Availability of data and materials: The datasets used and analyzed in the study are available from the corresponding author on reasonable request. Meetings: An abstract with limited data from this study was presented at the CORD 2022 meeting in San Diego, CA. Financial support: No financial support was received for this research. Conflict of Interest disclosure: None declared. Author Contributions: SM, SH, JT, and JH conceived the study design. SM and OL developed the intervention. SM and AF performed acquisition of the data and SM and AM analyzed and interpreted the data. SM drafted the manuscript and all authors critically reviewed and approved the final version. References Accreditation Council for Graduate Medical Education (ACGME). Emergency medicine defined key index procedure minimums: review committee for emergency medicine. 2017. 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AMEE Guide 14: Outcome-based education: Part 1-An introduction to outcome-based education. Med Teach. 1999;21(1):7–14. 10.1080/01421599979969 . Young JQ, Van Merrienboer J, Durning S, Cate OT. Cognitive Load Theory: Implications for medical education: AMEE Guide 86. Med Teach. 2014;36(5):371–84. Young J, Sewell J. Applying cognitive load theory to medical education: construct and measurement challenges. Perspect Med Educ. 2015;4(3):107–9. Kessler D, Pusic M, Chang TP, et al. Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture. Pediatrics. 2015;135(5):e1237–46. 10.1542/peds.2014 – 1911 . Braga MS, Tyler MD, Rhoads JM, et al. Effect of just-in-time simulation training on provider performance and patient outcomes for clinical procedures: a systematic review. BMJ Simul Technol Enhanc Learn. 2015;1(3):94–102. 10.1136/bmjstel-2015-000058 . PMID: 35515199; PMCID: PMC8936624. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Jun, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 25 Apr, 2024 Reviews received at journal 23 Apr, 2024 Reviews received at journal 10 Apr, 2024 Reviewers agreed at journal 31 Mar, 2024 Reviewers agreed at journal 28 Mar, 2024 Reviewers invited by journal 27 Mar, 2024 Editor assigned by journal 27 Mar, 2024 Editor invited by journal 27 Mar, 2024 Submission checks completed at journal 27 Mar, 2024 First submitted to journal 23 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Finch","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"S.","lastName":"Finch","suffix":""},{"id":285838954,"identity":"68371a21-de5a-47e7-950e-e949cc360cf8","order_by":2,"name":"Jenna M. Thomas","email":"","orcid":"","institution":"Washington University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jenna","middleName":"M.","lastName":"Thomas","suffix":""},{"id":285838955,"identity":"7edd7883-348f-4d2b-b477-57c1f9fe1a3f","order_by":3,"name":"Octavio Lazaro","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Octavio","middleName":"","lastName":"Lazaro","suffix":""},{"id":285838956,"identity":"2e443e3b-dc4f-43bf-9d33-65c0ff48481f","order_by":4,"name":"Sara A. Hevesi","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"A.","lastName":"Hevesi","suffix":""},{"id":285838957,"identity":"8e67c851-60ab-4ff5-b446-09b2993f6fec","order_by":5,"name":"Aidan F. Mullan","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Aidan","middleName":"F.","lastName":"Mullan","suffix":""},{"id":285838958,"identity":"d472e5f4-cc8c-4e06-97dc-f02946d84c77","order_by":6,"name":"Jim L. Homme","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Jim","middleName":"L.","lastName":"Homme","suffix":""}],"badges":[],"createdAt":"2024-03-23 04:44:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4152752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4152752/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-024-05654-1","type":"published","date":"2024-06-20T16:03:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53878067,"identity":"be20254a-f3e6-475f-b4cb-4e334ec8213c","added_by":"auto","created_at":"2024-04-01 16:58:05","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":457447,"visible":true,"origin":"","legend":"\u003cp\u003eProcedural Performance Assessment Setup with Pediatric LP Simulator II Model\u003csup\u003e5\u003c/sup\u003e and CareFusion Pediatric/Infant LP Tray\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4152752/v1/55c076e52111d767b978bf52.jpeg"},{"id":58823975,"identity":"5b4bda6d-104f-4ea5-943c-e184068e52cf","added_by":"auto","created_at":"2024-06-21 17:12:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":959796,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4152752/v1/85cc7cb5-8955-42ca-a157-7701c53e8a92.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Improving Emergency Medicine Resident Pediatric Lumbar Puncture Procedural Performance through a Brief Just-In-Time Video Intervention","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe Accreditation Council for Graduate Medical Education (ACGME) requires emergency medicine (EM) residencies to certify competence of trainees in procedures viewed as essential to the independent practice of EM.\u003csup\u003e1\u003c/sup\u003e Lumbar puncture (LP) is one of these procedures as it remains a mainstay of the diagnostic evaluation for patients with suspected central nervous system disorders due to infection, autoimmunity, and hemorrhage, and provides diagnostic and therapeutic benefit in cases such as idiopathic intracranial hypertension.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eImportance\u003c/h2\u003e \u003cp\u003eDespite its importance, trainee comfort level with the LP procedure has decreased over time due to changing practice guidelines, particularly amongst pediatric patients.\u003csup\u003e3\u003c/sup\u003e Across children\u0026rsquo;s hospitals nationwide, performance of LPs has decreased by 37% over the past decade, likely due to widespread vaccination and implementation of risk stratification algorithms that have changed the way febrile infants are managed in the emergency department (ED).\u003csup\u003e4\u003c/sup\u003e With decreasing clinical experience during training, average attending experience with the procedure is also expected to decrease, making effective standardized training interventions ever more important in competency-based medical education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eGoals of this investigation\u003c/h2\u003e \u003cp\u003eWe sought to improve competency at this increasingly rare procedure in our residency through a brief educational video, focusing initial efforts on our post-graduate year (PGY)-1 intern class.\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis experimental study took place January\u0026mdash;June 2022 within a large, academic Midwestern ED. The ED has an established 3-year EM residency with 9 residents per year and features both adult and pediatric care areas. A total of 32 LPs were performed in the ED on pediatric (\u0026lt;\u0026thinsp;18 years of age) patients between 7/1/2021 and 6/30/2022, 25 (78.1%) on patients\u0026thinsp;\u0026lt;\u0026thinsp;1 year of age. EM residents performed 17 (53.1%) of the total pediatric LPs, including 13 (52.0%) of the infant LPs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSelection of Participants\u003c/h2\u003e \u003cp\u003eIn January, all 9 EM interns were invited to participate in a \u0026ldquo;procedural project,\u0026rdquo; with the type of procedure blinded to participants. Participants were compensated with a \u003cspan\u003e$\u003c/span\u003e10 hospital cafeteria voucher, with an additional \u003cspan\u003e$\u003c/span\u003e5 bonus voucher offered if the entire class participated. The same compensation was offered at the time of post-intervention assessment in June. Informed consent of participants was obtained at time of assessment scheduling and re-obtained verbally at time of assessment performance. The study was reviewed by the Mayo Clinic Institutional Review Board and deemed exempt.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Measurement\u003c/h2\u003e \u003cp\u003eAt their individual baseline performance assessment, participants were provided the department\u0026rsquo;s standard CareFusion Pediatric/Infant LP Kit and asked to perform a timed diagnostic LP (including obtaining an opening pressure) on an infant LP model (Pediatric LP Simulator II Model).\u003csup\u003e5\u003c/sup\u003e Cerebrospinal fluid (CSF) was simulated by a hanging liter bag of saline connected to a rubber tube concealed within the model, allowing for flow with successful dura puncture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This simulated CSF flow, along with a tactile \u0026ldquo;pop\u0026rdquo; sensation with needle entry into the tube, allowed for recognition of penetration of the dura. Non-sheer tape was replaced over the spine before each trainee to obscure prior puncture marks.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePerformance was scored according to a previously validated LP Performance Scoring Checklist as described in Lammers et al.\u003csup\u003e3\u003c/sup\u003e A PGY-3 EM chief resident (S.M.) and EM attending physician (A.F.) observed and scored the assessments to assess competence (critical actions correctly performed) utilizing the checklist\u0026rsquo;s 26 major steps (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), defined by Lammers et al. as \u0026ldquo;critical steps that could cause a complication or procedural failure if omitted, performed incorrectly, or performed out of sequence.\u0026rdquo;\u003csup\u003e3\u003c/sup\u003e Lammers\u0026rsquo; 44 minor steps were omitted as some were optional variances in technique.\u003csup\u003e3\u003c/sup\u003e Participants were encouraged to verbalize their actions and were prompted, when necessary, to clarify details associated with a step (e.g. which bony landmark they were palpating and to which interspace level it corresponded). Timing began after instructions were given and ended after a bandage was placed and caps screwed onto all collection tubes. Participants received no feedback during or after the procedure and did not view the checklist being utilized.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCompletion of Major Steps (from previously published validated Performance Scoring Checklist to assess Competence in Lumbar Punctures\u003csup\u003e3\u003c/sup\u003e) at Baseline Procedural Performance Assessment compared to Post-Intervention Procedural Performance Assessment (N\u0026thinsp;=\u0026thinsp;9)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eTime to completion (minutes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValidation Item/ Major Step\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStep\u003c/p\u003e \u003cp\u003ePerformed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e12.9\u003c/p\u003e \u003cp\u003e(10.3, 14.4)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003cp\u003e10.3\u003c/p\u003e \u003cp\u003e(9.7, 11.3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlace the patient in a lateral decubitus position or upright position.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck the spine for maximum flexion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentify the L4-L5 interspace at the point intersecting the iliac crest line with the body midline.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePut on sterile gloves without contamination.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlace sponge stick into Betadine.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the skin in a circular motion from the target area to about a 10 cm radius.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsert the needle into the subcutaneous tissue.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInject 1\u0026ndash;3 cc of anesthetic solution.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlace the needle in the center of the interspace.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAngle the needle toward the umbilicus.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvance the needle into the skin slowly and smoothly.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (56%)\u003c/p\u003e \u003cp\u003e4 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce the needle passes through the subcutaneous tissue, turn the bevel of the needle laterally.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvance the needle.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemove the stylet and check for fluid.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReinsert the stylet.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvance the needle further until a pop is felt, an obstruction prevents further movement or the patient reports parasthesias or radicular pain.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e5 (56%)\u003c/p\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemove the stylet and check for fluid.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIf there is an obstruction and no fluid or if there are parasthesias and no fluid or if there is bright red blood, withdraw the needle and repeat the above 2 steps, reposition the needle or use a different interspace.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttach the manometer/stopcock to the needle hub.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTurn the stopcock valve until the dial is parallel with the manometer.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (56%)\u003c/p\u003e \u003cp\u003e4 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAllow the fluid to fill the manometer until the meniscus stops rising.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasure the CSF opening pressure correctly.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlace the first tube under the stopcock.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (56%)\u003c/p\u003e \u003cp\u003e4 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollect 1 cc of CSF.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScrew the cap on the first tube with one hand, and place the tube upright in the slot on the tray.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithdraw the needle.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003cp\u003e8 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003eItems marked as \u0026ldquo;N/A\u0026rdquo; (Not Applicable) indicate the participant successfully punctured the dura with CSF flow observed by step 7.4, thereby not requiring subsequent steps 7.5\u0026ndash;7.8. P-values comparing baseline and post-intervention assessments do not include \u0026ldquo;N/A\u0026rdquo; responses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eS.M. and O.L. designed and filmed a brief (4.25 minutes) instructional LP procedure video\u003csup\u003e6\u003c/sup\u003e that demonstrated the checklist's major steps (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The video was distributed via email in March to all trainees rotating through the ED and uploaded onto the department\u0026rsquo;s Intranet Education webpage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePost-Intervention Measurement\u003c/h2\u003e \u003cp\u003eAt the time of post-intervention assessment, participants were asked whether they had reviewed or utilized the video. Regardless of response, all participants were shown the video before proceeding with the same procedural assessment on the same infant LP model as performed at baseline, described above. This was done to ensure that the video was used as a JIT resource, as intended, rather than viewed at a time and location remote from procedural performance.\u003c/p\u003e \u003cp\u003eThe number of LPs logged by participants, as required by the residency, were pulled from the program\u0026rsquo;s graduate medical education (GME) administrative management software\u003csup\u003e7\u003c/sup\u003e in order to ascertain LP procedural experience at time of each assessment. Logged procedures could include those performed in the clinical and simulation settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eIntern performance on the LP Performance Scoring Checklist\u003csup\u003e3\u003c/sup\u003e was compared between baseline and post-intervention assessments using paired Fisher\u0026rsquo;s exact tests (completion of each major step) and Wilcoxon signed-rank tests (time to completion, total steps missed).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAll 9 interns completed both the baseline and post-intervention performance assessments. At the time of baseline assessment, interns had logged a median 4 (IQR 0\u0026ndash;10) LPs, with median 2 (IQR 0\u0026ndash;5) logged as \u0026ldquo;performed\u0026rdquo; (as opposed to simulated, observed, or assisted). Median baseline time to completion of the procedure was 12.9 (10.3\u0026ndash;14.4) minutes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Post-intervention, interns had logged an additional median of 4 (0\u0026ndash;11) LPs, including median 2 (IQR 0\u0026ndash;5) logged as \u0026ldquo;performed\u0026rdquo; and completed the procedure faster with a median time of 10.3 (9.7\u0026ndash;11.3) minutes (p\u0026thinsp;=\u0026thinsp;0.004). Three (33.3%) of the interns reported previously reviewing the video on their own. A median of 5 (\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) major steps were missed by each intern at baseline, compared to median 1 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) major step missed at time of post-intervention assessment (p\u0026thinsp;=\u0026thinsp;0.015).\u003c/p\u003e \u003cp\u003eInterns demonstrated either continued (n\u0026thinsp;=\u0026thinsp;8) or improved competency (n\u0026thinsp;=\u0026thinsp;17) of all major steps post-intervention, with the exception of turning the bevel of the needle laterally (Step 7.2). Among the major steps that were completed more frequently post-intervention, the only one reaching statistical significance was 7.1, advancement of the needle into the skin slowly and smoothly (p\u0026thinsp;=\u0026thinsp;0.037).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eInnovative approaches have historically been employed to provide medical trainees exposure to infrequent, invasive, and time-sensitive procedures which they may rarely, if ever, encounter.\u003csup\u003e8\u0026ndash;11\u003c/sup\u003e As the frequency of LPs performed in the clinical environment decreases, so too do trainees\u0026rsquo; encounters with them. Not only does the ACGME require residents to cite performance of a certain number of these procedures in order to graduate,\u003csup\u003e1\u003c/sup\u003e GME in the United States has moved towards a competence-based approach, requiring educators collect and demonstrate measurable evidence that trainees achieve specific, predetermined outcomes.\u003csup\u003e12\u0026ndash;13\u003c/sup\u003e Hidden amongst trainee data is the implication that as experience during training with a clinical procedure decreases, so too does the experience of the next generation of attending physicians who are responsible for supervising trainees. With increasing focus on managing (and measuring) cognitive load in medical education for both trainer and trainee, educational interventions which target optimization of cognitive load are expected to benefit clinical practice in both immediate and long-term settings.\u003csup\u003e14\u0026ndash;15\u003c/sup\u003e By utilizing a previously validated checklist in a brief JIT video, we ensure that agreed-upon elements of procedural competence are reliably demonstrated to the trainee independent of the supervising physician\u0026rsquo;s time, attention, or skill in teaching, all of which are particularly variable in the clinical environment where other departmental and patient care priorities must be balanced.\u003c/p\u003e \u003cp\u003eOur study demonstrates the benefit of utilizing a brief procedural video on both resident efficiency (time spent) and competence (critical actions correctly performed) in performing a LP. Given 66.7% of our cohort acknowledged watching the video for the first time at their post-assessment, our findings suggest a Just-In-Time (JIT) learning benefit, contrary to prior JIT LP studies that have demonstrated equivocal success.\u003csup\u003e16\u0026ndash;17\u003c/sup\u003e Similar efforts may improve education and performance of other rare procedures within EM training. We isolated the intern class as our intervention cohort given their expected novice baseline experience and competency with the procedure, as well as the need to improve upon both during their training. It is possible that the intervention had the same beneficial or a less beneficial impact amongst more senior EM residents or trainees from other specialties.\u003c/p\u003e \u003cp\u003eWe used a six-month time period between assessments to balance adequate time for simulation skill decay against clinical encounters allowing for LP performance. Participants documented performing a median of 2 LPs (and overall completing a median of 4 LPs) during the six months between baseline and post-intervention assessments, which was similar to the six months prior to baseline assessment (median 4 LPs, performed: p\u0026thinsp;=\u0026thinsp;0.81; completed: p\u0026thinsp;\u0026gt;\u0026thinsp;0.99). This suggests that exposure to the procedure external to our study likely had minimal influence on the improvement we observed in procedural efficiency and competency after our intervention.\u003c/p\u003e \u003cp\u003eOur study demonstrated benefit to trainee efficiency and competency after watching the video. However, only 1/3 of participants acknowledged having watched the video independently, and it is unclear to what degree attending physicians supervising these trainees utilized the video as a JIT tool as intended. Utilizing a brief video to provide JIT teaching and/or review has the benefit of cognitively offloading the supervising physician during the clinical shift, decreasing the required time away from other clinical responsibilities while being certain that all standardized evaluation (and by extension, competency) criteria have been demonstrated to the trainee by the video. Moreover, this allows a brief \u0026ldquo;refresher\u0026rdquo; of the procedure for the supervising physician if desired, particularly if they have not recently performed the procedure themselves. More effort is warranted to demonstrate the effectiveness and ease of use of similar JIT training videos to all stakeholders (trainer and trainee alike) in the future in order to encourage greater uptake.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThis study has several important limitations. Most salient is the small number of learners in our sample. We viewed this as a pilot to test whether a JIT video based on a validated checklist for procedural evaluation was effective in achieving increased procedural efficiency and/or competence, and feasible to design and distribute within a cohort of junior learners. Additionally, we did not independently verify trainee procedure logs, which could allow for error in entry by the performing resident. Administrative habits were thought likely to remain stable between the time of both assessments. We presented overall data of procedure logs, including number of LPs logged as having been directly performed and those logged as having been completed overall. We are unable to verify how many of these \u0026lsquo;completed\u0026rsquo; LPs were actually simulated, observed, or even supervised with performance feedback. Additionally, although we did not tell participants beforehand what procedure they would be asked to perform at time of their second (post-intervention) assessment, it is possible that they correctly assumed it would again be a LP and reviewed other resources to prepare. To mitigate this, we emphasized that performance would have no bearing on a participant\u0026rsquo;s residency evaluations. Although the simulator model used was high-quality, the static nature of our model does not fully replicate performing an LP procedure on a live infant. However, given the demonstrated decrease in availability of these procedures clinically, we believe our high-fidelity simulated model serves as the best available alternative. Finally, this study was performed within one academic EM residency program in the Midwest and may not be generalizable broadly to other training programs or institutions.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eDevelopment of a brief educational video improved efficiency and competency amongst our intern class in performing an infant LP when viewed Just-In-Time. Similar efforts may improve education and performance of other rare (or decreasing in frequency) procedures within EM training. Future research with other procedures, larger learner cohorts, and comparing JIT approaches will be necessary to determine whether JIT videos based on validated assessment checklists are truly \u0026ldquo;best practice\u0026rdquo;. Formal evaluation of the effect of similar \u0026ldquo;standardized\u0026rdquo; videos on cognitive load of learners and supervisors is also an important avenue of future research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent: Consent was obtained by all participants.\u0026nbsp;The study was reviewed by the Mayo Clinic Institutional Review Board and deemed exempt.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and analyzed in the study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eMeetings: An abstract with limited data from this study was presented at the CORD 2022 meeting in San Diego, CA.\u003c/p\u003e\n\u003cp\u003eFinancial support: No financial support was received for this research.\u003c/p\u003e\n\u003cp\u003eConflict of Interest disclosure: None declared.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions: SM, SH, JT, and JH conceived the study design. SM and OL developed the intervention. SM and AF performed acquisition of the data and SM and AM analyzed and interpreted the data. SM drafted the manuscript and all authors critically reviewed and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAccreditation Council for Graduate Medical Education (ACGME). Emergency medicine defined key index procedure minimums: review committee for emergency medicine. 2017. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.acgme.org/globalassets/pfassets/programresources/em_key_index_procedure_minimums_103117.pdf\u003c/span\u003e\u003cspan address=\"https://www.acgme.org/globalassets/pfassets/programresources/em_key_index_procedure_minimums_103117.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 20, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoherty CM, Forbes RB. Diagnostic lumbar puncture. Ulster Med J. 2014;83(2):93\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLammers RL, Temple KJ, Wagner MJ, Ray D. Competence of new emergency medicine residents in the performance of lumbar punctures. Acad Emerg Med. 2005;12:622\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeanacopoulos AT, Porter JJ, Michelson KA, et al. Declines in the number of lumbar punctures performed at United States children\u0026rsquo;s hospitals, 2009\u0026ndash;2019. J Pediatr. 2021;231:87\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKyoto Kagaku. Product Data: Pediatric Lumbar Puncture Simulator II. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kyotokagaku.com/en/products_data/m43d/\u003c/span\u003e\u003cspan address=\"https://www.kyotokagaku.com/en/products_data/m43d/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 30, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGuire SS, Lazaro O. Lumbar Puncture Procedural Video. Mayo Clinic Department of Emergency Medicine. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://drive.google.com/file/d/1_SxNqSgyPZTmzLwC4WWYVayp5dkYhl1j/view?usp=share_link\u003c/span\u003e\u003cspan address=\"https://drive.google.com/file/d/1_SxNqSgyPZTmzLwC4WWYVayp5dkYhl1j/view?usp=share_link\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 2, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedHub. Healthcare education, Residency Management Solutions. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.medhub.com\u003c/span\u003e\u003cspan address=\"https://www.medhub.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 2, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalm KH, Lei C, Walsh R, Heimiller J, Sikon J. An inexpensive, high-fidelity resuscitative hysterotomy (RH) model with hemorrhage capability. Cureus. 2022;14(6):e25582.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBengiamin DI, Toomasian C, Smith DD, Young TP. Emergency department thoracotomy: a cost-effective model for simulation training. J Emerg Med. 2019;57(3):375\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakowski AL. A survey of graduating emergency medicine residents\u0026rsquo; experience with cricothyrotomy. West J Emerg Med. 2013;14(6):654\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEllison S, Sullivan C, McCullough R. No longer waiting for an accident to happen: Simulation in emergency medicine. Mo Med. 2013;110(2):133\u0026ndash;8. (In eng).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIobst WF, Sherbino J, Cate OT, et al. Competency-based medical education in postgraduate medical education. Med Teach. 2010;32(8):651\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/0142159x.2010.500709\u003c/span\u003e\u003cspan address=\"10.3109/0142159x.2010.500709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarden RM. AMEE Guide 14: Outcome-based education: Part 1-An introduction to outcome-based education. Med Teach. 1999;21(1):7\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/01421599979969\u003c/span\u003e\u003cspan address=\"10.1080/01421599979969\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung JQ, Van Merrienboer J, Durning S, Cate OT. Cognitive Load Theory: Implications for medical education: AMEE Guide 86. Med Teach. 2014;36(5):371\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung J, Sewell J. Applying cognitive load theory to medical education: construct and measurement challenges. Perspect Med Educ. 2015;4(3):107\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKessler D, Pusic M, Chang TP, et al. Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture. Pediatrics. 2015;135(5):e1237\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2014\u0026thinsp;\u0026ndash;\u0026thinsp;1911\u003c/span\u003e\u003cspan address=\"10.1542/peds.2014\u0026thinsp;\u0026ndash;\u0026thinsp;1911\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraga MS, Tyler MD, Rhoads JM, et al. Effect of just-in-time simulation training on provider performance and patient outcomes for clinical procedures: a systematic review. BMJ Simul Technol Enhanc Learn. 2015;1(3):94\u0026ndash;102. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjstel-2015-000058\u003c/span\u003e\u003cspan address=\"10.1136/bmjstel-2015-000058\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35515199; PMCID: PMC8936624.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"lumbar puncture, procedural efficiency, resident education, emergency medicine, pediatric lumbar puncture, pediatric procedure, medical education, just-in-time education","lastPublishedDoi":"10.21203/rs.3.rs-4152752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4152752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003e Emergency medicine (EM) trainee comfort level with lumbar puncture (LP) has decreased over time due to changing practice guidelines, particularly amongst pediatric patients. We implemented a \u0026ldquo;just in time\u0026rdquo; (JIT) brief educational video based on a validated LP evaluation checklist to improve trainee efficiency and competence in LP performance.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eOur experimental study took place January-June 2022 within a large, academic Midwestern emergency department (ED) with an established 3-year EM residency program. All 9 interns performed a timed diagnostic LP on an infant LP model in January, scored according to a previously validated LP Performance Scoring Checklist. In June, interns repeated the timed LP procedure directly after watching a brief educational video based on major checklist steps. The study was deemed exempt by the Institutional Review Board.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eAll interns completed both assessments. At baseline, interns had logged performance of median 2 (IQR 0\u0026ndash;5) LPs and spent 12.9 (10.3\u0026ndash;14.4) minutes performing the procedure. Post-intervention, interns had logged an additional median 2 (0\u0026ndash;5) LPs and completed the procedure faster with an average time of 10.3 (9.7\u0026ndash;11.3) minutes (p\u0026thinsp;=\u0026thinsp;0.004). A median of 5 (\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) major steps were missed at baseline, compared to 1 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) at time of post-intervention assessment (p\u0026thinsp;=\u0026thinsp;0.015).\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eDevelopment of a brief educational video improved efficiency and competency amongst our intern class in performing an infant LP when viewed Just-In-Time. Similar efforts may improve education and performance of other rare (or decreasing in frequency) procedures within EM training. Future research with other procedures, larger learner cohorts, and comparing JIT approaches will be necessary to determine whether JIT videos based on validated assessment checklists are truly \u0026ldquo;best practice\u0026rdquo;. Formal evaluation of the effect of similar \u0026ldquo;standardized\u0026rdquo; videos on cognitive load of learners and supervisors is also an important avenue of future research.\u003c/p\u003e","manuscriptTitle":"Improving Emergency Medicine Resident Pediatric Lumbar Puncture Procedural Performance through a Brief Just-In-Time Video Intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-01 16:57:59","doi":"10.21203/rs.3.rs-4152752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-25T11:02:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-23T15:37:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-11T01:05:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a40427c0-c6c5-48a0-86d7-04e0a46977ce","date":"2024-03-31T12:08:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122d682d-ff0b-4c0c-966c-41e8e98c173d","date":"2024-03-28T11:57:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-27T22:38:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-27T22:37:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-27T19:28:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-27T18:41:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-03-23T04:31:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"235bb4e0-fd60-4c20-b510-8a9c3eebdbbf","owner":[],"postedDate":"April 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T16:03:19+00:00","versionOfRecord":{"articleIdentity":"rs-4152752","link":"https://doi.org/10.1186/s12909-024-05654-1","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-06-20 16:03:19","publishedOnDateReadable":"June 20th, 2024"},"versionCreatedAt":"2024-04-01 16:57:59","video":"","vorDoi":"10.1186/s12909-024-05654-1","vorDoiUrl":"https://doi.org/10.1186/s12909-024-05654-1","workflowStages":[]},"version":"v1","identity":"rs-4152752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4152752","identity":"rs-4152752","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}