Procedural Case: Neonatal Lumbar Puncture

This case was specifically designed for senior emergency medicine (EM) resident physicians as a preparatory tool for the American Board of Emergency Medicine (ABEM) Certifying Exam. However, it is applicable for EM residents at all levels of training.

Lumbar puncture (LP) is a critical diagnostic procedure in evaluating for central nervous system infections in febrile neonates. Recognizing its significance, ABEM has identified LP as a procedure that is integral to the practice of emergency medicine.1 Additionally, ABEM's new Certifying Exam, launching in 2026, will include LP among the procedural skills that examinees may encounter.2 Despite its importance, neonatal LP can be technically challenging, with reported success rates of only 50-60%.3 Many EM clinicians hesitate to perform the procedure due to concerns about complications and limited hands-on experience during residency training.4 Furthermore, the American Academy of Pediatrics' updated clinical practice guideline for the evaluation and management of febrile infants5 has led to a substantial decline in the number of LPs performed in this patient population,6 further reducing opportunities for trainees to gain clinical experience. This simulation case was designed to allow learners to practice and demonstrate the cognitive and technical skills necessary for performing a neonatal LP in a structured, risk-free environment.

This is a Procedure case involving a neonatal LP. The overarching educational goal of this case is to assess learners' clinical decision-making, technical proficiency, and communication skills when performing a neonatal LP. Participants will be evaluated on their ability to identify indications and contraindications, obtain informed consent, prepare for and perform the procedure with sterile technique, and implement appropriate post-procedure care. By the end of the session, learners should be able to: 1) describe the indications and contraindications associated with performing a neonatal LP, 2) obtain informed consent for a neonatal LP, using clear, patient-centered language to explain the procedure and to discuss risks, benefits, and alternative options, 3) demonstrate proper preparation for a neonatal LP, including equipment setup, patient positioning, patient monitoring, use of sterile technique, and analgesia, 4) perform a neonatal LP on a procedural task trainer with technical proficiency, demonstrating proper needle insertion, cerebrospinal (CSF) collection, and adherence to sterile technique, and 5) outline appropriate post-procedure management for the patient, including interpreting CSF results, initiating appropriate treatment, monitoring for complications, and providing caregivers with clear follow-up guidance.

We developed a single-station Objective Structured Clinical Examination (OSCE) centered on the neonatal LP procedure. This format aligns with the Procedures module of the new ABEM Certifying Exam, which emphasizes real-time procedural performance within simulated clinical encounters. This OSCE station incorporates a neonatal LP procedural task trainer and a standardized examiner script modeled after the ABEM Certifying Exam format to promote realism, consistency, and educational relevance. The case was collaboratively developed by experts in EM and simulation-based education and was externally peer-reviewed to ensure clinical accuracy, scenario clarity, and educational value. During the OSCE, the learner is presented with a brief case summary describing a febrile neonate requiring a lumbar puncture and is expected to demonstrate the essential cognitive and technical skills for performing the procedure. The examiner follows a structured script to deliver standardized prompts, offer procedural cues, and evaluate performance using a detailed, behaviorally anchored checklist that captures both procedural steps and critical decision-making elements.

The simulation case was originally developed by three experts in simulation-based education and EM. To enhance accuracy, realism, and educational value, the case underwent a structured peer review process involving a panel of three additional experts. Reviewers used the Simulation Scenario Evaluation Tool (SSET)7 to provide standardized feedback on key elements, including scenario flow, realism, clarity of learning objectives, and alignment with assessment criteria.The case was subsequently piloted at two academic institutions and a national EM conference to assess its feasibility, clarity, and instructional design in real-world educational settings. During these pilot sessions, faculty facilitators and participating learners interacted with the case using a standardized examiner script and procedural checklist. Feedback and observations from this testing informed refinements to case logistics, examiner prompts, and assessment criteria to enhance usability and educational effectiveness.

Our expert reviewers, using the SSET survey, strongly agreed that the simulation case's learning objectives were specific, action-oriented, relevant, and appropriately tailored to the target audience's skill level and knowledge base. They also strongly agreed that the clinical context, embedded critical actions, and patient states effectively supported these learning objectives. Faculty facilitators reported that the scenario materials and resources provided sufficient information to enable independent facilitation of the case at their own institutions. Participating learners indicated that the written materials and verbal instructions were clear and that the experience was valuable for preparing for the ABEM Certifying Exam.

This neonatal LP simulation case was effective in achieving its educational objectives and served as a valuable tool for preparing learners for the Procedures module of the ABEM Certifying Exam. Facilitators rated the case highly across key domains, highlighting the clarity, usability, and cohesiveness of the provided materials. Learners consistently reported that the scenario provided meaningful opportunities to practice both procedural skills and clinical reasoning. These findings support the incorporation of structured procedural OSCEs into EM training programs. By leveraging simulation, this case helps address educational gaps, promote consistency in training, and enhance learner preparedness for board certification.

Lumbar puncture, meningitis, procedure, American Board of Emergency Medicine, Certifying Exam.