Improving Infant Lumbar Puncture Clinical Outcomes Among Novices
We will conduct a prospective cohort study of interns at 36 participating centers (Appendix A). There will be two type of centers: 1. those that implement the minimum-competency based LP pathway and 2. those who do not implement the pathway. All sites will continue a mastery learning and just-in-time refresher training program that has been instituted previously.
Part of this curriculum includes a competency assessment immediately prior to clinical performance of this procedure (Appendix C). Interns who are judged as competent or proficient by their supervisors will then proceed with the procedure as per usual practice and local standards for supervision. All potential trainers will receive a brief training module on how to use the instrument (see INSPIRE website).
The key component that separates the two types of centers is how well they are able to implement the use of the competency assessment to determine whether the intern will be allowed to conduct their 1st clinical LP. Compliance with this approach will be measured and reported by site directors. The main outcome for the study is the change in intern 1st LP success prior to the the intervention (using historical controls) to post intervention. We will conduct our main analysis based on comparing overall LP success at sites who do implement the pathway to those who do not and perform sub-analyses to assess the effect of site.
Population. We will collect data at three levels: patient, intern and institution.At the site level, we will collect the following data: interns who perform an infant LP, whether they do so after a JIT assessment, and whether they have reported it. Each site will also keep track of what methods they use to disseminate the pathway. After 12 months, data will be analyzed and compared to historical control data. Qualitative data regarding barriers and facilitators of adherence to the competency-based protocol will be collected via interviews and focus groups of supervisors and learners. See appendix E for study timeline.
At the intern level, we will collect the following data: After their first infant lumbar puncture attempt, interns will be asked to anonymously report the results of the clinical encounter via a secure encrypted online questionnaire (appendix D). A five dollar gift card or similar value item will be offered after completion of the form in addition to a raffle entry for an item valued around $500 (such as an iPad).
Finally, we will collect data at the patient level whenever the intern performs an ILP. Our primary outcome measure is intern success with the first infant lumbar puncture performed after simulator training defined as CSF obtained on the first attempt and described as clear or with and amp;lt;1000 rbcs per hpf. Possible confounding variables including use of analgesia, early stylet removal, age of patient and holder will be collected on the anonymous self-report.
Enrollment into the Pediatric Residency Program as post-graduate year one physicians.