Clinical Application of Just-in-Time Training to Support Resident Learning and Success in Neonatal Intubation

Neonatal intubation (NI) requires technical skill and can cause life-threatening complications when performed improperly. Trainee success at NI is substandard, and nearly half of graduating trainees do not achieve the desired competency by the end of residency. This issue will likely worsen with the new ACGME rules that allow fewer intensive care rotations. The study objective was to evaluate if structured just-time-time-training (JITT) utilizing a high-fidelity neonatal mannequin was feasible and effective in a clinical environment and could improve trainee NI success. We hypothesized that JITT could be safely introduced in a clinical environment and that it would increase NI success overall, including more first-attempt success, decreased number of attempts and time-to-success, and decreased adverse outcomes.

Pediatric trainees who met the inclusion criteria and were in the neonatal intensive care unit during 2019-2020 were randomly assigned to a JITT or control group prior to performing an actual intubation. The JITT group received structured instruction on a neonatal mannequin and then simulated NI with immediate corrective feedback, whereas the control group did not receive any additional training.

A total of 31 intubation encounters were evaluated, involving 18 residents (JITT: n=16, 51.6%; control: n=15, 48.4%). The mean procedure time for successful intubation was significantly lower in the JITT group (117±66 seconds) compared to the control group (194±79 seconds; p=.029). The occurrence of adverse outcomes was significantly reduced in the JITT group (n=12, 75%) compared to the control group (n=15,100%; p=.045). While improvements were noted in the JITT group for overall success (12 (75%) vs. 8 (53%)) and first-attempt success (6 (37.5%) vs. 1 (6.7%)), these differences did not reach statistical significance (both p>.05). This improvement was upheld when only trainee first enrollments were evaluated.

This pilot study shows that targeted skills intervention via JITT is both feasible in a clinical environment and that it does improve trainee success. This concept deserves continued attention and would benefit from larger and multi-site studies to provide adequate powering to further evaluate success and secondary metrics such as time to success and occurrence of complications.