Screening residents for infant lumbar puncture readiness with just-in-time simulation-based assessments

Background Determining when to entrust trainees to perform procedures is fundamental to patient safety and competency development. Objective To determine whether simulation-based readiness assessments of first year residents immediately prior to their first supervised infant lumbar punctures (LPs) are associated with success. Methods This prospective cohort study enrolled paediatric and other first year residents who perform LPs at 35 academic hospitals from 2012 to 2014. Within a standardised LP curriculum, a validated 4-point readiness assessment of first year residents was required immediately prior to their first supervised LP. A score ≥3 was required for residents to perform the LP. The proportion of successful LPs (<1000 red blood cells on first attempt) was determined. Process measures included success on any attempt, number of attempts, analgesia usage and use of the early stylet removal technique. Results We analysed 726 LPs reported from 1722 residents (42%). Of the 432 who underwent readiness assessments, 174 (40%, 95% CI 36% to 45%) successfully performed their first LP. Those who were not assessed succeeded in 103/294 (35%, 95% CI 30% to 41%) LPs. Assessed participants reported more frequent direct attending supervision of the LP (diff 16%; 95% CI 8% to 22%), greater use of topical analgesia (diff 6%; 95% CI 1% to 12%) and greater use of the early stylet removal technique (diff 11%; 95% CI 4% to 19%) but no difference in number of attempts or overall procedural success. Conclusions Simulation-based readiness assessments performed in a point-of-care fashion were associated with several desirable behaviours but were not associated with greater clinical success with LP.