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Effect of just-in-time simulation training on provider performance and patient outcomes for clinical procedures: a systematic review
  1. Matthew S Braga1,2,3,
  2. Michelle D Tyler1,2,3,
  3. Jared M Rhoads1,
  4. Michael P Cacchio1,4,
  5. Marc Auerbach5,
  6. Akira Nishisaki6,
  7. Robin J Larson1,3,7
  1. 1The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
  2. 2The Children's Hospital at Dartmouth, Lebanon, New Hampshire, USA
  3. 3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
  4. 4Tuck School of Business at Dartmouth, Hanover, New Hampshire, USA
  5. 5Department of Pediatric Emergency Medicine, Yale School of Medicine, Yale, Connecticut, USA
  6. 6Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  7. 7VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont, USA
  1. Correspondence to Dr Matthew S Braga, Children's Hospital at Dartmouth, Pediatric Critical Care Medicine, One Medical Center Drive, Lebanon, NH 03756, USA; matthew.s.braga{at}


Background Providing simulation training directly before an actual clinical procedure—or ‘just-in-time’ (JiT)—is resource intensive, but could improve both provider performance and patient outcomes.

Objectives To assess the effects of JiT simulation training versus no JiT training on provider performance and patient complications following clinical procedures on patients.

Study selection We searched MEDLINE, Cochrane Library, CINAHL, PsycINFO, ERIC,, simulation journals indexes and references of included studies during October 2014 for randomised trials, non-randomised trials and before-after studies comparing JiT simulation training versus no JiT training among providers performing clinical procedures. Findings were synthesised qualitatively.

Findings Of 1805 records screened, 8 studies comprising 3540 procedures and 1969 providers were eligible. 5 involved surgical procedures; the other 3 included paediatric endotracheal intubations, central venous catheter dressing changes, or infant lumbar puncture. Methodological quality was high. Of the 8 studies evaluating provider performance, 5 favoured JiT simulation training with 18–48% relative improvement on validated clinical performance scales, 16–20% relative reduction in surgical time and 12% absolute reduction in corrective prompts during central venous catheter dressing changes; 3 studies were equivocal with no improvement in intubation success, lumbar puncture success or urological surgery clinical performance scores. 3 studies evaluated patient complications; 1 favoured JiT simulation training with 45% relative reduction in central line-associated blood stream infections; 2 studies found no differences following intubation or laparoscopic nephrectomy.

Conclusions JiT simulation training improves provider performance, but currently available literature does not demonstrate a reduction in patient complications.

  • just-in-time
  • systematic review
  • simulation
  • clinical competence

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