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 Medicine2McGill Pediatrics3McGill Centre for Medical Education &4Arnold and Blema Steinberg Centre for Medical Simulation

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 2007, Woollard 2004

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 Clerkship

Population

•Spaced instruction of a Pediatric Advanced Life Support-like course

Intervention

•Massed instruction of the exact same course

Comparison

•Procedural skills, knowledge retention, self-efficacy in pediatric resuscitation

Outcome

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 site

Design

•All clerks completing 8 weeks rotation in Pediatrics

Inclusion

•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

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

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

Results - IO

Spaced Groupn=23

Massed Groupn=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

Results - IO

Spaced Groupn=23

Massed Groupn=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

Results - BVMV

Spaced Groupn=23

Massed Groupn=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

Results - BVMV

Spaced Groupn=23

Massed Groupn=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

Results – Chest compressions

Spaced Groupn=23

Massed Groupn=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

Results – Chest compressions

Spaced Groupn=23

Massed Groupn=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

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

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

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

Acknowledgements

• McGill Emergency Medicine Resident Research Grant• Sophie Gosselin, Samara Zavalkoff, Mylene

Dandavino, Karen Trudel, Tanya Di Genova• Elise Mok

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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

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

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

Chest compression checklist

Course Outline

VAS

VAS