Putting the "learning" in "pre-learning": effects of a self-directed study hall on skill acquisition in a simulation-based central line insertion course.

BACKGROUND: Opportunities to practice procedural skills in the clinical learning environment are decreasing, and faculty time to coach skills is limited, even in simulation-based training. Self-directed learning with hands-on practice early in a procedural skill course might help maximize the benefit of later faculty coaching and clinical experience. However, it may also lead to well-learned errors if learners lack critical guidance. The present study sought to investigate the effects of a hands-on, self-directed "study hall" for central line insertion among first-year residents. METHODS: Learner cohorts before vs. after introduction of the study hall (n = 49) were compared on their pre- and post-test performance of key procedural behaviors that were comparable across cohorts, with all learners receiving traditional instructor-led training between tests. RESULTS: Study hall participants spent a median of 116 min in hands-on practice (range 57-175). They scored higher at pre-test (44% vs. 27%, p = .00; Cohen's d = 0.95) and at post-test (80% vs. 72%, p = .02; Cohen's d = 0.69). A dose-response relationship was found, such that 2 h of study hall were roughly equivalent to the performance improvement seen with four clinical observations or supervised insertions of central lines. CONCLUSIONS: Self-directed, hands-on "study hall" supported improved procedural skill learning in the context of limited faculty availability. Potential additional benefits make the approach worth further experimentation and evaluation.

Rapid response team-triggered procalcitonin measurement predicts infectious intensive care unit transfers*.

OBJECTIVE: Determine if procalcitonin at the time of initial rapid response team activation identifies patients who are likely to need subsequent intensive care unit transfer. DESIGN: Prospective observational cohort study. SETTING: Urban, tertiary care hospital with rapid response team activation through an electronic modified early warning score. PATIENTS: One hundred nineteen oncology and 100 consecutive non-oncology patients after initial rapid response team visit precipitated by an elevated electronic modified early warning score were recruited. Rapid response team activations by request of nursing or for other reasons were not studied. Five oncology patients seen by a rapid response team for complications of interleukin-2 therapeutic infusions were subsequently excluded. INTERVENTIONS: Residual serum from the next ordered clinical test (within 12 hrs) was retrieved, frozen, and stored for procalcitonin determination. A second sample 12-24 hrs after the initial specimen was also retrieved if available and if the patient had not yet been transferred to the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients (33%) were transferred to the intensive care unit. Rapid response team activations that did not result in intensive care unit transfer had significantly lower procalcitonin levels (median 0.28 ng/mL [interquartile range 0.09-1.24]) than those that resulted in intensive care unit transfer (median 0.51 ng/mL [interquartile range 0.11-1.97], p = .0001) but the area under the receiver operating curve was only 0.656. The change in procalcitonin level in patients with intensive care unit transfers was very heterogeneous but was significantly increased compared to the change in patients not transferred to the intensive care unit. Procalcitonin levels for intensive care unit transfers for probable or definite infection were 2.28 ng/mL [interquartile range 0.68-8.05], and were significantly greater than rapid response team visits that did not result in transfer (p = .0001). The difference between infectious and noninfectious intensive care unit transfers (0.95 ng/mL [interquartile range 0.26-1.89]) was also significant (p = .03). The procalcitonin levels of patients with noninfectious intensive care unit transfers were also different than the levels of patients who never transferred (p = .04). CONCLUSIONS: Preliminary results suggest procalcitonin levels in patients at the time of initial visit by a rapid response team correlate with the need for subsequent intensive care unit transfer, particularly for infectious reasons.

ISBARR Huddle: First-Year Medical Students Managing Critical Hypoglycemia as an Interprofessional Team.

Introduction: Recognizing a patient requiring urgent or emergent care and initiating evaluation and management must include elements that support teams working and thinking together. Although team communication strategies exist, a standardized approach for communicating about patients with urgent or emergent conditions is lacking. This simulation was designed to provide first-semester medical students with the opportunity to deliberately practice the foundational teamwork skills required to think as a team while caring for a patient with critical hypoglycemia. Methods: Students were introduced to a team huddle that was structured using ISBARR (identify, situation, background, assessment, recommend, recap) to assist in synthesizing gathered information and arriving at a diagnosis and associated care plan. Students practiced in small groups with faculty coaches and then applied the skills learned to two cases of a patient with critical hypoglycemia followed by debriefing. Results: Two hundred eight first-semester medical students participated in the simulation course across three campuses. We surveyed a single campus subset of 172 students. One hundred thirty-three students completed a postevent survey. The majority felt that the difficulty of the simulation was appropriate for their educational level (94%) and that the training would be applicable to real-life clinical events (76%) and would improve the quality and safety of care (100%). Survey comments highlighted teamwork and the use of the ISBARR huddle communication tool. Discussion: The course provided first-semester medical students with standardized practice of a team-based approach using huddle communication to advance patient care.

Deliberate practice and mastery learning in resuscitation education: A scoping review.

STUDY AIM: To summarize the current state of knowledge of deliberate practice and mastery learning (DP and/or ML) as teaching methods for resuscitation education. METHODS: A scoping review of PubMed, Scopus, and Embase was conducted through March 1, 2021. Studies examining the effect of the incorporation of either deliberate practice and/or mastery learning during resuscitation education were eligible for inclusion. Included studies were dichotomized into studies comparing deliberate practice and/or mastery learning to other training methods (randomized controlled trials) and studies examining before and after impact of deliberate practice and/or mastery learning alone (observational studies). Studies and findings were tabulated and summarized using the scoping review methodology published by Arksey and O'Malley. RESULTS: 63 published studies were screened; sixteen studies met all inclusion criteria (4 randomized controlled trials and 12 observational studies). One randomized controlled trial and eleven observational studies demonstrated improvement in skill and/or knowledge following educational interventions using deliberate practice and/or mastery learning. Significant variability between studies with regard to research designs, learner groups, comparators, and outcomes of interest made quantitative summarization of findings difficult. CONCLUSIONS: The incorporation of deliberate practice and/or mastery learning in resuscitation education may be associated with improved educational outcomes and less skill decay than other educational methods. Current literature on DP and ML suffers from a lack of consistency in research methodology, subjects, and outcomes. Future research should employ uniform definitions for deliberate practice and mastery learning, follow research design that isolates its effect, and examine generalizable and translatable outcomes.

Interprofessional Procedure Training for Medicine and Nursing Students.

Introduction: Recognizing the need for interprofessional education for trainees, the University of Kansas Schools of Nursing (SON) and Medicine (SOM) created interprofessional procedure workshops to foster collaboration, communication, and learning with and from other disciplines. The first workshop focused on venipuncture and peripheral intravenous catheter (PIV) insertion. Methods: An interprofessional work group including SON and SOM faculty developed a PIV procedure training workshop based on the "learn, see, practice, prove, do, maintain" framework. SON faculty and graduate nursing students provided support and mentoring during the training sessions. Nursing students acted as peer coaches for their medical student colleagues with the help of an evidence-based, standardized, deliberate practice guide. The document broke the procedure into phases-planning, preparation, insertion, and postinsertion care-and provided scaffolding for the beginner through assessment. Results: On survey, most students felt the program was beneficial and met the learning objectives. After the sessions, medical students completed a PIV assessment, and nursing students completed a reflection on the experience. These postsession assignments for each group confirmed that the learning objectives had been met. Discussion: The interprofessional PIV workshop was one module in a longitudinal interprofessional curriculum providing training for SON and SOM learners. One goal of this curriculum was to achieve higher graduate competencies in procedural skills and interprofessional practice. Additionally, in developing the workshop, a deliberate practice guide was created that provided an educationally sound and best-practice procedure to be standardized to all university learners on campus.

Balancing Deliberate Practice and Reflection: A Randomized Comparison Trial of Instructional Designs for Simulation-Based Training in Cardiopulmonary Resuscitation Skills.

INTRODUCTION: A key question in simulation-based education is how to maximize learning within time and resource limits, including how best to balance hands-on practice versus reflective debriefing. Several instructional design frameworks suggest setting the balance according to the type of learning objective(s); however, broad professional activities such as team-based cardiopulmonary resuscitation include several interrelated component skills. This study experimentally manipulated hands-on practice versus reflective debriefing for cardiopulmonary resuscitation skills, hypothesizing that the former best supports learning taskwork (eg, compression quality), whereas the latter best supports learning teamwork. METHODS: The study was a randomized comparison trial with a pretest and posttest. Twenty-six teams of 5 to 6 first-year residents underwent either "drill" practice of key resuscitation phases, designed to maximize deliberate practice opportunities for individual and team skills, or "scrimmage" practice, designed to maximize full-scenario rehearsals and reflective debriefs. Key taskwork and teamwork behaviors were coded, and compression quality was collected and analyzed from an accelerometer. RESULTS: Most performance parameters improved considerably from a pretest to posttest for both taskwork (eg, percent correct compression depth 62%-81%, P = 0.01) and teamwork (eg, role leadership, 47%-70%, P = 0.00). Only 2 parameters improved differently by condition, favoring "drill" training: checking "Do Not Actively Resuscitate" wristband (odds ratio = 14.75, P = 0.03) and use of compression adjuncts (estimated marginal means = 75% versus 67%, P = 0.03). CONCLUSIONS: Consistent with the notion that component skills in resuscitation do not clearly and exclusively constitute "taskwork" versus "teamwork," both instructional designs led to similar improvements despite differences in the balance between hands-on practice versus reflection.

Pretest Scores Uniquely Predict 1-Year-Delayed Performance in a Simulation-Based Mastery Course for Central Line Insertion.

INTRODUCTION: Within simulation-based mastery learning (SBML) courses, there is inconsistent inclusion of learner pretesting, which requires considerable resources and is contrary to popular instructional frameworks. However, it may have several benefits, including its direct benefit as a form of deliberate practice and its facilitation of more learner-specific subsequent deliberate practice. We consider an unexplored potential benefit of pretesting: its ability to predict variable long-term learner performance. METHODS: Twenty-seven residents completed an SBML course in central line insertion. Residents were tested on simulated central line insertion precourse, immediately postcourse, and after between 64 and 82 weeks. We analyzed pretest scores' prediction of delayed test scores, above and beyond prediction by program year, line insertion experiences in the interim, and immediate posttest scores. RESULTS: Pretest scores related strongly to delayed test scores (r = 0.59, P = 0.01; disattenuated ρ = 0.75). The number of independent central lines inserted also related to year-delayed test scores (r = 0.44, P = 0.02); other predictors did not discernibly relate. In a regression model jointly predicting delayed test scores, pretest was a significant predictor (ß = 0.487, P = 0.011); number of independent insertions was not (ß = 0.234, P = 0.198). CONCLUSIONS: This study suggests that pretests can play a major role in predicting learner variance in learning gains from SBML courses, thus facilitating more targeted refresher training. It also exposes a risk in SBML courses that learners who meet immediate mastery standards may be incorrectly assumed to have equal long-term learning gains.

The Effect of Model Fidelity on Learning Outcomes of a Simulation-Based Education Program for Central Venous Catheter Insertion.

INTRODUCTION: Simulation-based education for central venous catheter (CVC) insertion has been repeatedly documented to improve performance, but the impact of simulation model fidelity has not been described. The aim of this study was to examine the impact of the physical fidelity of the simulation model on learning outcomes for a simulation-based education program for CVC insertion. METHODS: Forty consecutive residents rotating through the medical intensive care unit of an academic medical center completed a simulation-based education program for CVC insertion. The curriculum was designed in accordance with the principles of deliberate practice and mastery learning. Each resident underwent baseline skills testing and was then randomized to training on a commercially available CVC model with high physical fidelity (High-Fi group) or a simply constructed model with low physical fidelity (Low-Fi group) in a noninferiority trial. Upon completion of their medical intensive care unit rotation 4 weeks later, residents returned for repeat skills testing on the high-fidelity model using a 26-item checklist. RESULTS: The mean (SD) posttraining score on the 26-item checklist for the Low-Fi group was 23.8 (2.2) (91.5%) and was not inferior to the mean (SD) score for the High-Fi group of 22.5 (2.6) (86.5%) (P < 0.0001). Residents in both groups judged the training program to be highly useful despite perceiving a lesser degree of physical realism in the low-fidelity model compared with the high-fidelity model (P = 0.05). CONCLUSIONS: Simulation-based education using equipment with low physical fidelity can achieve learning outcomes comparable with those with high-fidelity equipment, as long as other aspects of fidelity are maintained and robust educational principles are applied during the design of the curriculum.