Just-in-time training

I came across a very interesting study published in December, 2024 in the British Medical Journal ("Coaching inexperienced clinicians before a high stakes medical procedure: Randomised clinical trial").  The study was conducted in the operating rooms at Boston Children's Hospital by investigators in the Departments of Pediatrics and Anesthesia at Harvard Medical School and involved what is commonly referred to as "just-in-time training" (JIT).  Specifically, investigators wanted to test whether JIT would increase the first-attempt success rate of intraoperative tracheal intubation.  

Tracheal intubation involves placing a breathing tube into the trachea, and while it is one of the most commonly performed procedures in the operating room, it does require a certain degree of knowledge and technical skill.  Tracheal intubation can be a potentially life-saving procedure for patients who are having difficulty breathing.  However, in the operating room environment, tracheal intubation is performed in order to facilitate protection of the airway reflexes and maintenance of breathing during the administration of general anesthesia.  If not performed correctly, attempts at tracheal intubation can result in cardiac arrest.

The team of investigators in this study recognized that like physicians and nurses, many professions outside of the health care industry (e.g. musicians, athletes, pilots, etc) receive many hours of highly structured coaching and practice in order to develop expertise.  However, unlike physicians and nurses, the individuals in these professions also universally rehearse these skills right before a performance or sporting event, similar to "just-in-time training".  Given that tracheal intubation is a technical procedure that requires practice and expertise, why wouldn't physicians (tracheal intubation is usually performed by physicians or specialized nurses called nurse anesthetists) rehearse or practice right before being called upon to perform the procedure?

Just over 150 physicians in training participated in the study.  All study participants performed intraoperative tracheal intubation in infants less than 12 months of age.  They were divided into two different groups.  The first group received "just-in-time training" via a coaching session and simulated tracheal intubation (on a manikin) prior to stepping into the operating room.  The second group did not receive "just-in-time training" and instead followed routine practice, which included unstructured coaching in the operating room while being supervised by an attending anesthesiologist.

Overall, the 150 physicians performed over 500 intubations on children less than 12 months of age during the study period, which lasted approximately 2 years.  The first-attempt success rate for tracheal intubation was significantly higher in the group that received "just-in-time training" (91.4% versus 81.6%), regardless of their previous level of training.  Other factors were better in the "just-in-time training" group as well - including decreased time to intubation, fewer advancement maneuvers, and fewer technical difficulties.  

The key factor to "just-in-time training" is to bring the time between training and implementation for a procedure much closer together.  This elegant study shows that "just-in-time training" can significantly increase the success rate of one of the most commonly performed procedures in the operating room.  Based on these results, one is tempted to ask whether we should be using "just-in-time training" more commonly in medicine.  I think so.