A distributed learning strategy improves performance and retention of skills in neonatal resuscitation A simulation-based randomized controlled trial
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Published:
Feb 13, 2022
Keywords:
Resuscitation, High Fidelity Simulation Training, Learning, Pediatrics, Neonatology
Main Article Content
Abstract
Skill retention after neonatal resuscitation training is poor. A distributed learning strategy – where learning is spread over multiple sessions – can improve retention of declarative memory (facts & knowledge). Session timings are critical – maximal retention occurs when a refresher session is scheduled at 10-30% of the time between initial training and test. We hypothesized this also holds true for neonatal resuscitation, a complex skill set requiring both declarative and procedural memory. We conducted a prospective, single-blinded randomized-controlled trial. University of Ottawa residents were recruited to training in neonatal resuscitation, with a high-fidelity simulated pre-test, immediate post-tests, and a retention test at 4 months. After training, they were randomized to either a refresher session at 3 weeks (18% of interval) or at 2 months (50%). Technical and non-technical skills were scored using validated checklists, knowledge with standardized questions. There was no difference between groups prior to the retention test. The early refresher group demonstrated significantly improved technical (mean ± 95% CI: 22.4 ± 1.3 v 18.2 ± 2.5, p = 0.02) and non-technical (31.0 ± 0.9 v 25.6 ± 3.1, p = 0.03) skill scores in the retention post-test compared to the late group. No difference was seen with knowledge scores. We conclude that both technical and non-technical aspects of neonatal resuscitation performance can benefit from an early refresher session. Session timings are critical and should be tailored to the desired length of skill retention. Findings may be generalizable to other interventions that depend on mixed types of memory.
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Original Research
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References
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21. Levitt C, Kaczorowski J, Outerbridge E. Knowledge Gained Following Neonatal Resuscitation Program Courses. Family Medicine 1996; 28: 403-406.
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23. Woollard M, Whitfield R, Newcombe RG, Colquhoun M, Vetter N, Chamberlain D. Optimal refresher training intervals for AED and CPR skills: A randomized controlled trial. Resuscitation 2006; 71: 237-247. doi:10.1016/j.resuscitation.2006.04.005.
24. Cepeda NJ, Pashler H, Vul E, Wixted JT, Rohrer D. Distributed practice in verbal recall tasks: A review and quantitative synthesis. Psychological Bulletin 2006; 132: 354-380. doi:10.1037/0033-2909.132.3.354.
25. Rohrer D, Pashler H. Increasing retention without increasing study time. Current Directions in Psychological Science 2007; 16: 183-186.
26. Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ. Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback. Anesthesiology 2006; 105: 279-285.
27. American Academy of Pediatrics, American Heart Association, eds. NRP Neonatal Resuscitation Textbook 6th Edition (English Version). American Academy of Pediatrics; 2011.
28. Lockyer J, Singhal N, Fidler H, Weiner G, Aziz K, Curran V. The Development and Testing of a Performance Checklist to Assess Neonatal Resuscitation Megacode Skill. Pediatrics 2006; 118: e1739-e1744. doi:10.1542/peds.2006-0537.
29. Kim J, Neilipovitz D, Cardinal P, Chiu M, Clinch J. A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study. Critical Care Medicine 2006; 34: 2167-2174. doi:10.1097/01.CCM.0000229877.45125.CC.
30. Lockyer J, Singhal N, Fidler H, Weiner G, Aziz K, Curran V. The Development and Testing of a Performance Checklist to Assess Neonatal Resuscitation Megacode Skill. Pediatrics 2006; 118: e1739-e1744. doi:10.1542/peds.2006-0537.
31. Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. British Journal of Anaesthesia 2009; 103: 570-575. doi:10.1093/bja/aep221.
32. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods 2007; 39: 175-191. doi:10.3758/BF03193146.
33. Landis JR, Koch GG. An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics 1977; 33: 363-374.
34. Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. Anesthesiology 2010; 112: 985-992. doi:10.1097/ALN.0b013e3181d3e31c.
35. Riem N, Boet S, Bould MD, Tavares W, Naik VN. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. British Journal of Anaesthesia 2012; 109: 723-728. doi:10.1093/bja/aes256.
36. Lee KH, Angus DC, Abramson NS. Cardiopulmonary resuscitation: what cost to cheat death? Critical Care Medicine 1996; 24: 2046-2052.
37. Trevisanuto D, Ferrarese P, Cavicchioli P, Fasson A, Zanardo V, Zacchello F. Knowledge gained by pediatric residents after neonatal resuscitation program courses. Pediatric Anesthesia 2005; 15: 944-947. doi:10.1111/j.1460-9592.2005.01589.x.
38. Boet S, Bould MD, Fung L, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Canadian Journal of Anesthesia 2014; 61: 571-582. doi:10.1007/s12630-014-0143-8.
39. Dubos J, Cosson M, Truffert P, et al. Meconium aspiration syndrome in the region of Nord-Pas-de-Calais. Development of a training program for neonatal resuscitation. Archives de Pédiatrie 1992; 49: 165-169.
40. Duran R, Aladağ N, Vatansever Ü, Süt N, Acunaş B. The impact of Neonatal Resuscitation Program courses on mortality and morbidity of newborn infants with perinatal asphyxia. Brain and Development 2008; 30: 43-46. doi:10.1016/j.braindev.2007.05.009.
2. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015; 95: e169-e201. doi:10.1016/j.resuscitation.2015.07.045.
3. Skidmore MB, Urquhart H. Retention of skills in neonatal resuscitation. Paediatrics and Child Health 2001; 6: 31-35.
4. Sawyer T, Sierocka-Castaneda A, Chan D, Berg B, Lustik M, Thompson M. Deliberate Practice Using Simulation Improves Neonatal Resuscitation Performance. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 2011; 6: 327-336. doi:10.1097/SIH.0b013e31822b1307.
5. Trevisanuto D, Ferrarese P, Cavicchioli P, Fasson A, Zanardo V, Zacchello F. Knowledge gained by pediatric residents after neonatal resuscitation program courses. Pediatric Anaesthesia 2005; 15: 944-947. doi:10.1111/j.1460-9592.2005.01589.x.
6. Xu T, Wang HS, Ye HM, Yu RJ, Huang XH. Impact of a nationwide training program for neonatal resuscitation in China. Chinese Medical Journal (English) 2012; 125: 1448-1456. doi:10.3760/cma.j.issn.0366-6999.2012.08.017.
7. Goudar SS, Somannavar MS, Clark R, Lockyer JM. Stillbirth and newborn mortality in India after helping babies breathe training. Pediatrics 2013; 131: e344-e352. doi:10.1542/peds.2012-2112.
8. Patel D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a Statewide Neonatal Resuscitation Training Program on Apgar Scores Among High-Risk Neonates in Illinois. Pediatrics 2001; 107: 648-655.
9. Kaczorowski J, Levitt C, Hammond M, et al. Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial. Family Medicine 1998; 30: 705-711.
10. Arthur W Jr, Bennett W Jr, Stanush PL, McNelly TL. Factors That Influence Skill Decay and Retention: A Quantitative Review and Analysis. Human Performance 1998; 11: 57-101. doi:10.1207/s15327043hup1101_3.
11. Mosley C, Shaw B. A longitudinal cohort study to investigate the retention of knowledge and skills following attendance on the Newborn Life support course. Archives of Disease in Childhood 2013; 98: 582-586. doi:10.1136/archdischild-2013-303953.
12. Finn JC, Bhanji F, Lockey A, et al. Part 8: Education, implementation, and teams: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015; 95: e203-e224. doi:10.1016/j.resuscitation.2015.07.046.
13. Kurosawa H, Ikeyama T, Achuff P, et al. A Randomized, Controlled Trial of In Situ Pediatric Advanced Life Support Recertification (“Pediatric Advanced Life Support Reconstructed”) Compared With Standard Pediatric Advanced Life Support Recertification for ICU Frontline Providers. Critical Care Medicine 2014; 42: 610-618. doi:10.1097/CCM.0000000000000024.
14. Bender J, Kennally K, Shields R, Overly F. Does simulation booster impact retention of resuscitation procedural skills and teamwork? Journal of Perinatology 2014; 34: 664-668. doi:10.1038/jp.2014.72.
15. Jensen ML, Mondrup F, Lippert F, Ringsted C. Using e-learning for maintenance of ALS competence. Resuscitation 2009; 80: 903-908. doi:10.1016/j.resuscitation.2009.06.005.
16. Karpicke JD, Bauernschmidt A. Spaced retrieval: Absolute spacing enhances learning regardless of relative spacing. Journal of Experimental Psychology: Learning, Memory, and Cognition 2011; 37: 1250-1257. doi:10.1037/a0023436.
17. Xue G, Mei L, Chen C, Lu Z-L, Poldrack R, Dong Q. Spaced learning enhances subsequent recognition memory by reducing neural repetition suppression. Journal of Cognitive Neuroscience 2011; 23: 1624-1633. doi:10.1162/jocn.2010.21532.
18. Sobel HS, Cepeda NJ, Kapler IV. Spacing effects in real-world classroom vocabulary learning. Applied Cognitive Psychology 2010; 25: 763-767. doi:10.1002/acp.1747.
19. Moulton C-AE, Dubrowski A, MacRae H, Graham B, Grober E, Reznick R. Teaching Surgical Skills: What Kind of Practice Makes Perfect? Transactions of the Meeting of the American Surgical Association 2006; 124: 66-75. doi:10.1097/01.sla.0000234808.85789.6a.
20. Bjerrum AS, Eika B, Charles P, Hilberg O. Distributed practice. The more the merrier? A randomized bronchoscopy simulation study. Medical Education Online 2016; 21: 30517–6. doi:10.3402/meo.v21.30517.
21. Levitt C, Kaczorowski J, Outerbridge E. Knowledge Gained Following Neonatal Resuscitation Program Courses. Family Medicine 1996; 28: 403-406.
22. Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation 2008; 78:59-65. doi:10.1016/j.resuscitation.2008.02.007.
23. Woollard M, Whitfield R, Newcombe RG, Colquhoun M, Vetter N, Chamberlain D. Optimal refresher training intervals for AED and CPR skills: A randomized controlled trial. Resuscitation 2006; 71: 237-247. doi:10.1016/j.resuscitation.2006.04.005.
24. Cepeda NJ, Pashler H, Vul E, Wixted JT, Rohrer D. Distributed practice in verbal recall tasks: A review and quantitative synthesis. Psychological Bulletin 2006; 132: 354-380. doi:10.1037/0033-2909.132.3.354.
25. Rohrer D, Pashler H. Increasing retention without increasing study time. Current Directions in Psychological Science 2007; 16: 183-186.
26. Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ. Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback. Anesthesiology 2006; 105: 279-285.
27. American Academy of Pediatrics, American Heart Association, eds. NRP Neonatal Resuscitation Textbook 6th Edition (English Version). American Academy of Pediatrics; 2011.
28. Lockyer J, Singhal N, Fidler H, Weiner G, Aziz K, Curran V. The Development and Testing of a Performance Checklist to Assess Neonatal Resuscitation Megacode Skill. Pediatrics 2006; 118: e1739-e1744. doi:10.1542/peds.2006-0537.
29. Kim J, Neilipovitz D, Cardinal P, Chiu M, Clinch J. A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study. Critical Care Medicine 2006; 34: 2167-2174. doi:10.1097/01.CCM.0000229877.45125.CC.
30. Lockyer J, Singhal N, Fidler H, Weiner G, Aziz K, Curran V. The Development and Testing of a Performance Checklist to Assess Neonatal Resuscitation Megacode Skill. Pediatrics 2006; 118: e1739-e1744. doi:10.1542/peds.2006-0537.
31. Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. British Journal of Anaesthesia 2009; 103: 570-575. doi:10.1093/bja/aep221.
32. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods 2007; 39: 175-191. doi:10.3758/BF03193146.
33. Landis JR, Koch GG. An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics 1977; 33: 363-374.
34. Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. Anesthesiology 2010; 112: 985-992. doi:10.1097/ALN.0b013e3181d3e31c.
35. Riem N, Boet S, Bould MD, Tavares W, Naik VN. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. British Journal of Anaesthesia 2012; 109: 723-728. doi:10.1093/bja/aes256.
36. Lee KH, Angus DC, Abramson NS. Cardiopulmonary resuscitation: what cost to cheat death? Critical Care Medicine 1996; 24: 2046-2052.
37. Trevisanuto D, Ferrarese P, Cavicchioli P, Fasson A, Zanardo V, Zacchello F. Knowledge gained by pediatric residents after neonatal resuscitation program courses. Pediatric Anesthesia 2005; 15: 944-947. doi:10.1111/j.1460-9592.2005.01589.x.
38. Boet S, Bould MD, Fung L, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Canadian Journal of Anesthesia 2014; 61: 571-582. doi:10.1007/s12630-014-0143-8.
39. Dubos J, Cosson M, Truffert P, et al. Meconium aspiration syndrome in the region of Nord-Pas-de-Calais. Development of a training program for neonatal resuscitation. Archives de Pédiatrie 1992; 49: 165-169.
40. Duran R, Aladağ N, Vatansever Ü, Süt N, Acunaş B. The impact of Neonatal Resuscitation Program courses on mortality and morbidity of newborn infants with perinatal asphyxia. Brain and Development 2008; 30: 43-46. doi:10.1016/j.braindev.2007.05.009.