The Problem

Idea Series LogoProcedural training is critical in emergency medicine (EM). EM residents must effectively acquire the skills to safely and accurately perform high-stakes, invasive, and life-saving procedures during high-pressure scenarios. Residency programs typically incorporate procedural skills workshops into didactic sessions, which results in residents practicing procedures several weeks or months before performing them clinically. Unfortunately, there is no established method to practice and evaluate procedural skills competency immediately prior to performing invasive procedures on a patient. A solution to this issue may lead to improved outcomes and greater patient safety.

The Innovation: Just-in-Time Procedural Training for Endotracheal Intubation

Just-in-time Training (JITT) has been proposed as a training methodology to reduce adverse events associated with high-stakes procedures by allowing residents to practice and learn procedural skills and muscle memory immediately prior to performing the procedure on a patient.1 While traditional procedural training involves classroom based simulation skills workshops, JITT brings live simulation to the bedside. The clinician receives training “just-in-time,” when it is needed most: moments before the procedure.

JITT decreases the time to successful completion of procedures, and may even play a role in long-term retention of procedural skills.2 It has also been described in reducing undesirable outcomes in pediatric intubations and thus may improve patient safety.2 Simulation-assisted JITT can be applied for most ED procedures, including endotracheal tube (ETT) placement, central venous catheter (CVC) placement, laceration repair, and lumbar puncture.

This post focuses on JITT as an educational adjunct for ETT placement in the clinical learning environment.

procedural training

A task trainer specific to the chosen procedure is necessary for JITT.

For the supervising faculty member unfamiliar with a resident’s procedural competency, JITT is an opportunity to observe the trainee’s skills before the procedure is performed on the patient.

The Learners

Our JITT targets EM residents, but can also be applied to medical students or faculty members performing an unfamiliar procedure.

ACGME EM Milestones

EM residents are expected to be competent at performing and troubleshooting multiple invasive procedures.

  • General Approach to Procedures (PC9): “Performs indicated procedure on any patients with challenging features… takes steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure” (Level 4)
  • Airway Management (PC10): “Performs airway management in any circumstance, taking steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure” (Level 4)
  • Other Diagnostic and Therapeutic Procedures (PC13): “Performs advanced wound repairs, such as tendon repairs and skin flaps” (Level 5)
  • Other Diagnostic and Therapeutic Procedures (PC14): “Routinely gains venous access in patients with difficult vascular access” (Level 4)

Required Materials

All that is needed to facilitate JITT is a low-fidelity task trainer specific to the chosen procedure. Both high- and low-fidelity task trainers are commercially available. Ideally, this should be a portable model that can be stored and easily accessed in your ED. If possible, real equipment and adjuncts (i.e., ETT, laryngoscope, bag-valve-mask) should be set aside and dedicated for JITT.

Prior to beginning a JITT intervention for a procedure in your ED, a checklist of critical actions should be generated to help the supervisor coach the trainee through the critical steps of the procedure. This checklist can integrate departmental policies or tools (i.e., airway kit) into training.

Just In Time Training 2

Example of real airway supplies next to a task trainer to be used for JITT

Description of the Innovation

Once the ED team identifies a patient for an invasive procedure, the preceptor (i.e., supervising faculty member / senior resident) and the learner (i.e., the resident performing the procedure) will apply JITT by carrying out the following steps:

  • The instructor and learner review the procedure, with a focus on the most critical and invasive aspects of the procedure.
  • The preceptor instructs the learner to perform the procedure on the task trainer as if it were a real patient using the checklist of critical actions. In the case of a learner utilizing JITT for ETT intubation, examples of skills that can be practiced include:
    • Proper positioning of the patient
    • Effective bag-valve-mask ventilation techniques
    • Correctly maneuvering a laryngoscope
    • Visualizing the vocal cords and the glottic opening
    • Successfully placing the ETT through the glottic opening
    • Correctly using airway adjuncts, if needed, as rescue airway devices (ex: bougie, laryngeal mask airway (LMA), glidescope)
  • The preceptor monitors the learner’s performance with each tool and device.
  • The preceptor provides continuous formative feedback. As the learner correctly demonstrates each of these critical steps on the task trainer, through deliberate practice and formative feedback, he/she should progress through all steps until mastery level is achieved, and until the supervising physician is comfortable with the trainee’s demonstrated procedural skills.
  • The learner is encouraged to ask questions throughout the process.

The trainee practices on the task trainer until ready to perform the procedure on the patient.

Just in Time Training 6

Following successful JITT, the trainee then performs the procedure on the patient.

Lessons Learned

We performed JITT intervention for stable ETT intubations in our ED with junior residents and precepting faculty. Qualitative review of feedback from these sessions demonstrated that:

  • JITT increased learner confidence during the actual intubation, as residents had a chance to review important kinesthetic skills (i.e., opening the mouth; angling the laryngoscope; manipulating the larynx).
  • Faculty found the opportunity to correct mistakes and optimize performance was immediately transferrable to the actual intubation moments later.
  • Residents felt that the actual intubation felt less challenging than prior intubations they’ve performed in the past without JITT.
  • Residents and faculty commented on minimal adverse events associated with preceding JITT with high self-reported first-pass success rate of ETT intubation.
  • In future studies, the authors would suggest examining patient safety indices pre- and post-intervention with regards to the incidence of adverse airway-associated events peri-intubation (i.e., tube misplacement, airway trauma, aspiration).

Theory behind the innovation

Simulation has been used for decades to improve learner’s procedural performance. Educators are now beginning to implement in situ simulation training to make the simulations higher fidelity for clinical teams. In situ training brings simulation into the clinical environment, allowing learners to practice in their natural setting. JITT, a form of in situ simulation training, offers an opportunity to improve resident education, patient outcomes, and operator confidence while performing the procedure.

Just in Time Training 5

A preceptor reviews key aspects of the procedure with the trainee during JITT.

Closing Thoughts

Simulation is an established educational adjunct to teach high-stakes EM procedures. Traditional classroom based simulation, however, fails to provide real-time, real-place practice opportunities for learners. Furthermore, the temporal gap between simulation training and actual clinical performance may be so long that the learner might have forgotten critical aspects of the procedure. JITT offers the opportunity to practice and teach procedures in situ, immediately before performing the procedure on an actual patient. This improves patient safety, reduces error, and improves provider confidence. Considering the implications on patient safety and learner outcomes, JITT should be considered a viable educational intervention in the clinical environment for teaching invasive procedures.

Photo credits: Lightbulb (c) Can Stock Photo

Ericsson KA, Krampe RT, Tesch-Romer C. The Role of Deliberate Practice in the Acquisition of Expert Performance. Psychological Review. 1993;100(3):363-406.
Nishisaki A, Donoghue A, Colborn S, et al. Effect of just-in-time simulation training on tracheal intubation procedure safety in the pediatric intensive care unit. Anesthesiology. 2010;113(1):214-223. [PubMed]
Dimitrios Papanagnou, MD, MPH, EdD(c)

Dimitrios Papanagnou, MD, MPH, EdD(c)

Vice Chair for Education
Department of Emergency Medicine
Assistant Dean, Faculty Development
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Clara Akayuli, MD

Clara Akayuli, MD

EM Resident
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Morgan Oakland, MD

Morgan Oakland, MD

EM Resident
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA