Cognitive load during training for out-of-department emergency responses

Emergency medicine (EM) physicians sometimes respond to critical events outside the emergency department. To prepare for these complex cases-typically called "rapid responses" (RRs)-EM residents receive simulation-based training involving four practice tasks and three exam tasks during a 1-day session. Cognitive load (CL) theory describes how humans function with limited working memories to perform complex tasks. RRs are expected to generate high levels of CL, but the profile of CL across providers and RR cases is not well understood. In this study, we analyzed resident's CL during RR training. We hypothesized variations in CL across individual and case and that exam cases would cause higher CLs than practice cases.

Residents anonymously self-reported CL levels after each case using the Paas scale, a single-item, 9-point scale from "very, very low CL" to "very, very high CL." To examine case-based differences in CL, data were rescaled by individual residents. "High CL" was defined as a score of 9/9.

Among 18 residents participating, CLs ranged from 4 to 9, with median of 7 and interquartile range of 7-8. While many cases showed bell curve-like distributions of CLs, one case-a bleeding tracheostomy-showed a rightward skew reflecting higher levels of CL. No significant difference was found in CL between practice and exam cases. There were 20 reports (16.5%) of "high" CL with variation across residents (0/7 [0%] to 5/6 [83.3%] cases) and across cases (1/18 [5.6%) to 8/18 [44.4%]).

The CL that EM residents experienced did show considerable interpersonal and intercase variation, but there was no significant difference between practice and exam cases. These results highlight several questions about how to optimally design future training, including how best to balance low and high CL training cases and which cases may require further training.