The Impact of Massed versus Spaced
Instruction on Learning of
Procedural Skills in
Pediatric Resuscitation
Catherine Patoc...
Disclosure Statement
I have no actual or potential conflict of interest in relation to this
presentation.

Rationale
Camp 1997, Ali 1993, Burnbaum 1994, Carcillo 2009 Hamilton 2005,
Wright 1989, Hunt 2008, Smith 2008, Spooner 200...
Rationale
TIME
Massed Instruction
Rationale
Spaced Instruction
Glenberg 1980, Toppino 1991, Dail 2004,Edelson 2006, Bhanji 2010
Research Question
Bhanji 2011
• 3rd year medical students in Pediatric
Core ClerkshipPopulation
• Spaced instruction of a ...
TIME
Massed Instruction
300min
75min
Spaced Instruction
Legend
Lecture
Case-based
Procedural
1 wk
Methods
Methods
• Cohort study using a convenience
sample at a single siteDesign
• All clerks completing 8 weeks rotation
in Pedia...
Outcome measures
Chest compression assessment tools
• Checklist and Global rating scale
• Quantitative assessment
Bag valv...
Results
N = 52
Spaced group
24
Spaced group
23
4
Excluded
Massed group
24
Massed group
22
• 1 previously completed PALS
• ...
Results - IO
Spaced
Group
n=23
Massed
Group
n=22
P-value
Mean global rating scale ±SD 3.4±0.9 3.2±0.7 0.482
Mean checklist...
Results - IO
Spaced
Group
n=23
Massed
Group
n=22
Odds ratio
(95% CI)
P-value
Describes the
appropriate landmark
20 12 5.6 ...
Results - BVMV
Spaced
Group
n=23
Massed
Group
n=22
P-value
Mean global rating score ±SD 2.1±1.1 2.2±1.2 0.730
Mean checkli...
Results - BVMV
Spaced
Group
n=23
Massed
Group
n=22
Odds ratio
(95% CI)
P-value
Has oxygen turned on
during BVMV
22 7 47.1
...
Results – Chest compressions
Spaced
Group
n=23
Massed
Group
n=22
P-value
Mean global rating scale
±SD
3.0±1.2 2.6±1.0 0.34...
Results – Chest compressions
Spaced
Group
n=23
Massed
Group
n=22
Odds
ratio
(95% CI)
P-value
Quantitative chest
compressio...
Limitations
• Checklist items not weighted according
to expert opinion
• Global scales anchored inappropriately
• Not vali...
Conclusion
• Students taught pediatric resuscitation in a spaced
format performed at least as well as students
taught in a...
Implications
• Very few interventions have been shown to impact
student learning in resuscitation skills
• The results fur...
Acknowledgements
• McGill Emergency Medicine Resident Research Grant
• Sophie Gosselin, Samara Zavalkoff, Mylene
Dandavino...
References
• Ali J, Adam R, Butler AK, et al. Trauma outcome improves following the advanced
trauma life support program i...
References
• Dail TK, Christina RW. Distribution of practice and metacognition in learning and
long-term retention of a di...
References
• Kromann CB, Jensen ML, Ringsted C. The effect of testing on skills learning. Med Educ.
2009;43:21-27.
• Nadel...
IO Checklist
• Describes the appropriate landmark on a manikin? Y/N
• Properly prepares the insertion site? Y/N
• Properly...
BVMV checklist
• Chooses correct mask and bag size? Y/N
• Oxygen turned on during BVMV? Y/N
• Properly positions the patie...
Chest compression checklist
• Places hand(s) correctly on the chest (based on landmarks)?
Y/N
• Chooses appropriate compre...
Chest compression checklist
Course Outline
VAS
VAS
The Impact of Massed versus Spaced Instruction on Learning of Procedural Skills in Pediatric Resuscitation
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The Impact of Massed versus Spaced Instruction on Learning of Procedural Skills in Pediatric Resuscitation

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Authors:
F.A. Khan, MDCM, C. Patocka, MDCM, F. Bhanji, MD, MSc, I. Bank, MDCM, FRCPC, FAAP, A. Dubrovsky, MDCM, MSc, FRCPC, D. Brody, MD, FRCPC;

McGill Emergency Medicine Residency Program

Introduction:
Survival from cardiac arrest has been linked to the quality of resuscitation care. Unfortunately, health care providers frequently underperform in these critical scenarios, with a well-documented deterioration in skills following an advanced life support course. Improving initial training and preventing decay in knowledge and skills are a priority in resuscitation education. The purpose of this study was to determine if a resuscitation course taught in a spaced format compared to the usual “massed” instruction results in improved procedural skills.
Methods:
We delivered a case-based pediatric resuscitation course to two cohorts of medical students: one in a spaced format (four 75-minute weekly sessions) and the other in a massed format (a single 5-hour session). Four weeks following course completion, blinded observers assessed each learner at various skills stations. Primary outcomes were performance on bag-valve-mask ventilation (BVMV), intraosseous (IO) insertion, and chest compressions using expert-developed checklists. Secondary outcomes included performance of “key components” of the above skills.
Results:
Forty-five of 48 students completed the study protocol (23 spaced and 22 massed). Students in the spaced cohort scored higher overall for BVMV (6.9 ± 1.4 v. 5.8 ± 1.9, p < 0.04), without significant differences in scores for IO insertion (3.9 ± 1 v. 3.7 ± 1.2, p = 0.575) and chest compressions (10.9 ± 2.7 v. 10.1 ± 2.4, p = 0.342). They were also more likely to administer oxygen during BVMV (OR 47.2, 95% CI 5.2- 423, p < 0.001), adhere to a target ventilation rate (OR 4.9, 95% CI 1.1- 21.2, p < 0.03), use a stool when appropriate for chest compressions (OR 8.3, 95% CI 1.2-59, p < 0.03), and landmark correctly for IO insertion (OR 5.4, 95% CI 1.3-24.3, p < 0.02). The intervention group also had a significantly shorter mean time to IO insertion (30.2 ± 34 seconds v. 62.1 ± 30 seconds, p = 0.002).
Conclusion:
Infrequent yet critically important procedures learned in a spaced format may result in better skill retention and more efficient task completion when compared to traditional massed training.

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  • When it comes advanced life support survival is related to the quality of resuscitation, studies have shown a clear link between training and performance of the provider. 1-4there is little evidence on which specific interventions enhance learning and retention from Courses like ACLS and PALS
  • complex motor skills are required for procedures in Pediatric resuscitation such as intraosseous insertion, bag valve mask ventilation and cardiac compressions
  • Traditionally courses have typically been taught in a massed format (meaning that lessons take place over a short period of time). However HCP have limited retention, demonstrating deterioration of skills in weeks to months following a course,certainly well before the standard retraining period of 2 yearsThe educational psychology literature suggests that spacing out lessons as opposed to giving them in one shot (or bolus) leads to more efficient learning and less decay. To our knowledge we are the first to examine spaced instruction within the advanced life support context
  • We hypothesized that 3rd year pediatric clerkships students given a previously described PALS-like course in a spaced format versus a traditional Massed format, would learn better. We focused primarily on Procedural skillsbut also looked at knowledge and self-efficacy.If asked about course:Previously published pediatric resuscitation designed course for Medical Students Do medical students feel that pediatric resuscitation should be mandatory ?
  • We taught an identical course 2 formats, that consisted of some didactic teaching, but mostly case-based learning and practical skills sessions. The massed format was taught in one 5 hour block of time and spaced format was taught in 4 75min blocks each 1 week apart.
  • We enrolled 2 consecutive, demographically similar cohorts of clerks on rotation in Pediatrics at the MCH , excluded those who were already PALS certified or would a priori be unable to attend testing, which occurred 4 weeks after the end of each course.(our study deliberately avoids learner preparation prior to the course as well as immediate end of course assessment because there is evidence that testing prior to and after the instructional phase of learning has an impact on learning and might mask any difference made by our intervention)
  • Participants were assessed for performance in IO insertion, BVMV and Chest compressions by independent blinded evaluators trained in using tools we developedsince No validated tools exist in the literatureThe first tool was a checklist that included parameters used in previous studies evaluating these procedural skills and highlighted elements that were a priori deemed critical by our panel of expertsThere was also a Global rating scale was an anchored 5-point likert scale of overall performance For chest compressions we added Quantitative Assessment using a (Zoll) CPR accelerometer and its accompanying software (RescueNet Code Review)Target rates of compression were 90-120 cpm, and depth 3-5cm which corresponded to 1/3 depth of manikin’s AP diameter
  • Of the 52 eligible participants, 4 met exclusion criteria and 3 were lost to follow up, leaving 22 and 23 participants in each arm
  • Our results were as follows:for IO insertion, There was no difference in the global rating scale and mean checklist score however students in the spaced group were more efficient in completing the task, finishing on average 32 seconds faster than their counterparts, taking less than half the time
  • As I mentioned before we a priori selected checklist items that we deemed “critical” and compared their performance between the 2 groupsFor IO insertion there were 2 critical items, describing appropriate landmarks and verifying that the IO is stable in the bone. Participantsin the spaced group were more than 5 times more likely to landmark correctly, meaningMore students would put it in the right place!
  • for BVMV, While results in the mean global rating scale showed no difference between the groups, there was a small but statistically significant improvement in checklist scores in the spaced group
  • Here, critical steps were the use of oxygen, adherence to a target rate of ventilation to avoid hypo or hyperventilation(target 15-25) And the correct choice of mask and bag size. In each of these, the spaced group performed significantly better.In particular, they were 47 times more likely to use oxygen when bagging!
  • For Chest compressions the global rating and checklist scores were similar, with differences that were not statistically significant
  • Quantitative assessment of chest compressions using the accelerometer calculated the % of compressions that were within the target rate between 90 and 120 cpm and the target depth of 1/3 the AP diameter of the Manikin (in this case between 3 and 5 cm) The groups were also not significantly different in this regard. Additional critical steps for this procedure were correcthand placement on the pediatric manikin and the use of a stool if necessary (based on their height and the table height) to achieve efficient compressions, and the spaced group performed better in the latter.(They were not taught using the accelerometer, so we expected poor performance comparatively. This also highlights how poorly we can judge compression performance visually. Most ALS courses in Canada are not taught using accelerometers so the study design is more generalizable in our context)
  • We feel the major Limitation of our study lies in the assessment tools. The checklist items were created from a list provided by experts but were not weighted for importance. When we looked at the critical elements independently, there were significant differences between the groups but not in their overall mean checklist scores. The global rating scales also did not show any differences and this may have been due to how we anchored the scores, for example the lack of oxygen suggested the evaluator assign a score of 2/5 when perhaps it should have been lower in retrospect. For these reasons we feel that we may have underestimated differences between the groupsOther limitations include the decay period of 4 weeks which was chosen to maximize follow-up and though a more relevant follow-up period would probably be 6 months, studies have shown decay as early as 2 weeksIt is possible that the effects may be more or less pronounced after 6 months, we have a plan to retest the student at 12 monthsOther possible limitations:Convenience sampling: true randomization not really possible since there is high risk of cross contamination between students of each group when it comes to learned material since they are working in the same environment, therefore temporally spaced cohorts were used.(May have led to curving or normalization of results by one evaluator who compared each participant to the average performance of the group they were evaluated in rather than the entire study population)the tool itself: should undergo validation process by independent evaluators (novice vs expert) and kappa value determination.
  • We also looked at self efficacy which is not data that we are presenting here today but we found that while both groups had improved confidence in their abilities from before to immediately after the course, only the spaced group retained this self confidence 4 weeks later, while the massed group already started to show significant decay.(In pediatric resuscitation it has been shown that quality of resuscitation is related to one’s self-efficacy in the simulated environment)
  • The Impact of Massed versus Spaced Instruction on Learning of Procedural Skills in Pediatric Resuscitation

    1. 1. The Impact of Massed versus Spaced Instruction on Learning of Procedural Skills in Pediatric Resuscitation Catherine Patocka1,3, Farooq Khan1, Sasha Dubrovsky2, Danny Brody2, Ilana Bank2,3,4 & Farhan Bhanji2,3,4 1McGill Emergency Medicine 2McGill Pediatrics 3McGill Centre for Medical Education & 4Arnold and Blema Steinberg Centre for Medical Simulation
    2. 2. Disclosure Statement I have no actual or potential conflict of interest in relation to this presentation. 
    3. 3. Rationale Camp 1997, Ali 1993, Burnbaum 1994, Carcillo 2009 Hamilton 2005, Wright 1989, Hunt 2008, Smith 2008, Spooner 2007, Woollard 2004
    4. 4. Rationale
    5. 5. TIME Massed Instruction Rationale Spaced Instruction Glenberg 1980, Toppino 1991, Dail 2004,Edelson 2006, Bhanji 2010
    6. 6. Research Question Bhanji 2011 • 3rd year medical students in Pediatric Core ClerkshipPopulation • Spaced instruction of a Pediatric Advanced Life Support-like courseIntervention • Massed instruction of the exact same courseComparison • Procedural skills, knowledge retention, self-efficacy in pediatric resuscitationOutcome
    7. 7. TIME Massed Instruction 300min 75min Spaced Instruction Legend Lecture Case-based Procedural 1 wk Methods
    8. 8. Methods • Cohort study using a convenience sample at a single siteDesign • All clerks completing 8 weeks rotation in PediatricsInclusion • Prior successful PALS completion • A priori inability to attend testing sessions Exclusion • Procedural skills testing 4 weeks post course completion • No immediate testing of learners Outcome Denton 2004, Kroman 2009, Kroman 2009
    9. 9. Outcome measures Chest compression assessment tools • Checklist and Global rating scale • Quantitative assessment Bag valve mask ventilation (BVMV) assessment tool • Checklist and Global rating scale Intraosseous (IO) assessment tool • Checklist and Global rating scale Adapted from Nadel 2000, Quan 2001, Gerard 2006
    10. 10. Results N = 52 Spaced group 24 Spaced group 23 4 Excluded Massed group 24 Massed group 22 • 1 previously completed PALS • 3 a priori absent for testing • 2 lost to follow-up in Massed • 1 lost to follow-up in Spaced
    11. 11. Results - IO Spaced Group n=23 Massed Group n=22 P-value Mean global rating scale ±SD 3.4±0.9 3.2±0.7 0.482 Mean checklist score ±SD 3.9±1 3.7±1.2 0.575 Mean time to insertion (seconds)±SD 30.2±34 62.1±30 0.002
    12. 12. Results - IO Spaced Group n=23 Massed Group n=22 Odds ratio (95% CI) P-value Describes the appropriate landmark 20 12 5.6 (1.3-24.3) 0.016 Verifies that the IO is stable in the bone 9 6 1.7 (0.5-6.0) 0.40
    13. 13. Results - BVMV Spaced Group n=23 Massed Group n=22 P-value Mean global rating score ±SD 2.1±1.1 2.2±1.2 0.730 Mean checklist score ±SD 6.9±1.7 5.8±1.9 0.032
    14. 14. Results - BVMV Spaced Group n=23 Massed Group n=22 Odds ratio (95% CI) P-value Has oxygen turned on during BVMV 22 7 47.1 (5.3-423) 0.0001 Adheres to the target ventilation rate 10 3 4.9 (1.1-21) 0.027 Chooses correct mask and bag size 22 16 8.3 (0.9-75.4) 0.034
    15. 15. Results – Chest compressions Spaced Group n=23 Massed Group n=22 P-value Mean global rating scale ±SD 3.0±1.2 2.6±1.0 0.344 Mean checklist score ±SD 10.9±2.7 10.1±2.4 0.342
    16. 16. Results – Chest compressions Spaced Group n=23 Massed Group n=22 Odds ratio (95% CI) P-value Quantitative chest compression performance (% within target rate and depth) 31.3±37.8 27.1±29.2 0.674 Correct hand placement during CPR 19 18 1.1 (0.2-4.9) 0.945 Uses a stool to perform CPR (if necessary) 6/10 2/13 8.3 (1.2-59) 0.026
    17. 17. Limitations • Checklist items not weighted according to expert opinion • Global scales anchored inappropriately • Not validated for inter-rater reliability (kappa) Assessment tools • 4 week period maximized follow-up • More clinically relevant period = 6 months • Studies have shown decay as early as 2 weeks Short decay period Hunt 2008, Wright 1989, Hamilton 2005
    18. 18. Conclusion • Students taught pediatric resuscitation in a spaced format performed at least as well as students taught in a massed format, and in fact had improved skill performance on critical steps one month post-course completion and were more efficient to complete tasks
    19. 19. Implications • Very few interventions have been shown to impact student learning in resuscitation skills • The results further our understanding of students’ retention of resuscitation course material • Spacing led to significant differences on multiple critical steps in resuscitation procedures • May influence how resuscitation courses are taught in the future
    20. 20. Acknowledgements • McGill Emergency Medicine Resident Research Grant • Sophie Gosselin, Samara Zavalkoff, Mylene Dandavino, Karen Trudel, Tanya Di Genova • Elise Mok
    21. 21. References • Ali J, Adam R, Butler AK, et al. Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma. 1993;34:890-8; discussion 898-9. • Bandura, A Self-efficacy: Toward a Unifying Theory of Behavioral Change, Psychological Review 1977, Vol 84, No.2, 191-215 • Bhanji F, Mancini ME, Sinz E, Rodgers DL, McNeil MA, Hoadley TA, et al. Part 16: Education, implementation, and teams: 2010 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122(18_suppl_3):S920. • Bhanji, F, Gottesman R, de Grave W, et al. Paediatric Resuscitation Training--Do Medical Students Believe It Should Be a Mandatory Component of the Curriculum? Resuscitation. 2011:82:584-587 • Birnbaum ML, Robinson NE, Kuska BM, Stone HL, Fryback DG, Rose JH. Effect of advanced cardiac life-support training in rural, community hospitals. Crit Care Med. 1994;22:741-749. • Camp BN, Parish DC, Andrews RH. Effect of advanced cardiac life support training on resuscitation efforts and survival in a rural hospital. Annals of Emergency Medicine. 1997;29:529- 533. • Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics. 2009;124:500.
    22. 22. References • Dail TK, Christina RW. Distribution of practice and metacognition in learning and long-term retention of a discrete motor task. Res Q Exerc Sport. 2004;75:148-155. • Denton GD, Durning SJ, Wimmer AP, Pangaro LN, Hemmer PA. Is a faculty developed pretest equivalent to pre-third year GPA or USMLE step 1 as a predictor of third-year internal medicine clerkship outcomes? Teaching and learning in medicine. 2004;16:329. • Edelson DP, Abella BS et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006, Nov;71(2):137-45 • Gerard Jm et al, Evaluation of a Novel Web-Based Pediatric Advanced Life Support Course, Arch Pediatr Adolesc Med. 2006;160:649-655 • Glenberg AM, Lehmann TS. Spacing repetitions over 1 week. Mem Cognit. 1980;8:528-538. • Hamilton R. Nurses' knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature. J Adv Nurs. 2005;51:288-297. • Hunt EA, Fiedor-Hamilton M, Eppich WJ. Resuscitation education: narrowing the gap between evidence-based resuscitation guidelines and performance using best educationalpractices. Pediatr Clin North Am. 2008;55:1025-50, xii. • Kromann CB, Bohnstedt C, Jensen ML, Ringsted C. The testing effect on skills learning might last 6 months. Advances in health sciences education. 2009:1-7.
    23. 23. References • Kromann CB, Jensen ML, Ringsted C. The effect of testing on skills learning. Med Educ. 2009;43:21-27. • Nadel FM et al, Assessing pediatric senior residents’ training in resuscitation: Fund of knowledge, technical skills, and perception of confidence. Pediatric Emergency Care 2000;16(2):73-76 • Quan L, Shugerman RP, Kunkel NC, Quan L. Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course. Pediatrics. 2001;108:e110. • Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation. 2008;78:59-65. • Spooner BB, Fallaha JF, Kocierz L, Smith CM, Smith SC, Perkins GD. An evaluation of objective feedback in basic life support (BLS) training. Resuscitation. 2007;73:417-424. • Toppino TC, Kasserman JE, Mracek WA. The effect of spacing repetitions on the recognition memory of young children and adults. J Exp Child Psychol. 1991;51:123-138 • Turner NMB, Lukkassen I, Bakker N, Draaisma J, ten Cate OTJ. The effect of the apls-course on self-efficacy and its relationship to behavioural decisions in paediatric resuscitation. Resuscitation 2009;80(8):913-8. • Woollard M, Whitfeild R, Smith A, et al. Skill acquisition and retention in automated external defibrillator (AED) use and CPR by lay responders: a prospective study. Resuscitation. 2004;60:17-28. • Wright S, Norton C, Kesten K. Retention of infant CPR instruction by parents. Pediatr Nurs.1989;15:37-41, 44.
    24. 24. IO Checklist • Describes the appropriate landmark on a manikin? Y/N • Properly prepares the insertion site? Y/N • Properly assembles the EZ-IO components? Y/N • Properly positions the leg on a manikin? Y/N • Verifies that the IO is stable in the bone? Y/N • Time to insertion
    25. 25. BVMV checklist • Chooses correct mask and bag size? Y/N • Oxygen turned on during BVMV? Y/N • Properly positions the patient? Y/N • Pressure on the soft tissues of the neck during BVMV? Y/N • Achieves appropriate mask seal during BVMV? Y/N • Rate of ventilation: • Chooses appropriate OPA when asked to insert one? Y/N • Inserts the OPA using the correct technique Y/N
    26. 26. Chest compression checklist • Places hand(s) correctly on the chest (based on landmarks)? Y/N • Chooses appropriate compression technique (hand encircling, two-fingers, one-handed or two-hand)?Y/N • Uses a stool, if necessary? Y/N • Performs chest compression with arm(s) outstretched and elbow(s) locked? Y/N
    27. 27. Chest compression checklist
    28. 28. Course Outline
    29. 29. VAS
    30. 30. VAS

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