Third-year medical students were randomized to either massed (300 minutes continuous) or spaced (75 minutes per session over 4 weeks) instruction on pediatric resuscitation procedures. Students in the spaced group performed intraosseous insertion faster and were more likely to describe landmarks and verify placement. For bag-valve-mask ventilation, the spaced group was more likely to turn on oxygen and adhere to ventilation rates. There were no significant differences for chest compressions. Spaced practice may better support retention of critical resuscitation skills compared to massed instruction.
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Impact of Massed vs Spaced Learning on Pediatric Resuscitation Skills
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
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
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. 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. 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
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. 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. 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. 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. 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. 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. Acknowledgements
• McGill Emergency Medicine Resident Research Grant
• Sophie Gosselin, Samara Zavalkoff, Mylene
Dandavino, Karen Trudel, Tanya Di Genova
• Elise Mok
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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. 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. 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
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)