Procedural readiness of pediatric interns: defining novice performance through simulation

Pediatric lumbar puncture (LP) is a common invasive procedure performed by physicians in training. The Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education recognize simulation as a tool for deliberate practice and standardized assessment of procedural performance. We sought to perform a detailed review of simulated LP performance to elucidate reasons for pediatric residents' reported 26% failure rate. Participants were enrolled in a single 30-minute session between July 2008 and January 2009. Data collected included former experience and training via questionnaire and video review of intern performance of a simulated LP on an infant model. Intern performance was assessed against a list of 10 procedural elements. Acquisition of cerebrospinal fluid (CSF), the number of elements performed on the first 2 attempts, and specific types of training/experience were analyzed for associations. All 32 enrolled interns endorsed receiving some previous LP training. Training on a model was infrequent (38%). Interns reported performing a median of 2 LPs prior to enrollment (interquartile range, 2-4). Seven of 31 interns (22%) had yet to perform a live LP. Eleven of 32 interns (34%; 95% confidence interval [CI], 18%-51%) acquired CSF during the first 2 simulated attempts. No specific type of prior training or experience was statistically associated with either the number of procedural elements or successful CSF acquisition (all P > .05). Interns performed a median of 7 of 10 procedural elements (interquartile range, 5.5-8). Early stylet removal was never performed. Complete removal of the stylet with all CSF checks was significantly associated with CSF acquisition (odds ratio, 9; 95% CI 0.98, 84.2). Avoidance of a spinous process upon skin entry was associated with a trend toward increased CSF acquisition (odds ratio, 3.5; 95% CI 0.76, 16.1). Despite performing many common procedural elements, pediatric interns generally lack the ability to successfully acquire CSF during a simulated infant LP. Expert performance of an infant LP likely requires complete stylet removal with each check for CSF and early spinous process avoidance. A simulated infant LP allowed assessment of intern procedural performance as well as description of elements critical to successful CSF acquisition.