1. Assoc Prof Tim Shaw, Director Workforce Education & Development Group (WEDG), The University of Sydney James Nicholson, Educational Development Manager, WEDG, The University of Sydney Dr Anna DiMarco, Director of Training, Hospital Skills Program SES & IS Local Health Districts

3. The Challenge ‘ Traditional types of CME have only a modest impact on clinician’s knowledge retention and clinical behaviour’ Cochrane Database of Systematic Review 2009(2) Forsetlund et al

4. The Challenge

5. JMO Context Vulnerable Workloads, inexperience and competing learning opportunities potentially places the JMO at increased risk of being involved in adverse outcomes Gen Y and Z enjoy electronic based media

6. HSP Context Enhance the HSP workshops by reinforcing learning objectives Impacts on HSP participant knowledge and behaviour Is quick to complete Supports objectives of patient safety and governance

7. Spaced Education – in a nutshell Only takes a few minutes each day Course is spread out over a period of weeks Proven in randomised trials to improve knowledge retention and improve behaviour better than traditional online learning Works extremely well on smart-phones (optimised for iPhone, Android and BlackBerry) or a desktop computer.

8. Spaced Education is a novel form of evidence based online education based on 2 core psychological research findings of spacing and testing effects

9. A novel approach  The testing effect  The spacing effect

10. Spacing effect – refers to the finding that educational encounters repeated over time leads to knowledge acquisition and retention

11. Testing effect – refers to the finding that ‘the process of testing’ measures knowledge and alters the learning processes to significantly improve knowledge retention

12. Each Spaced Ed Case Study consists of an: 1. Educative component eg MCQ 2. Evaluative component (correct answer and feedback with a detailed explanation of correct and incorrect answers) 3. Spaced Ed item is repeated – fixed number of times

13. Vol 211, No 3, September 2010 Kerfoot et al Spaced Education Generates Skill Transfer

17. HSP Program – Spaced Ed 2 x 20 Spaced Ed Cases Post test evaluation survey Not a randomised control trial Behavioural changes not examined

18. Child – Elbow Pain A 6 year old child presents with a painful elbow after an unwitnessed injury. Attached is his X-ray: Aims Which of the following is most correct? A. There is no obvious injury and so a pulled elbow is likely B. The medial epicondyle is displaced suggesting an avulsion fracture C. There is no evidence of a fat pad sign, so a soft tissue injury is likely D. The x-rays are inadequate and further views are needed Answer D Case studies which reinforce previous LBOSs

19. Take home message When assessing an injury understand the signs of possible injury, but ensure you have the appropriate view to make your assessment. In this case the x-rays are inadequate and further views are needed. Feedback Pulled elbows do not require x-rays and are diagnosed with an appropriate history (remember that 50% of pulled elbows DO NOT give a history of being pulled), and an examination that generally has no area of tenderness or upper limb joint dysfunction, other than a reluctance to, and stress associated with, attempted gentle pro and supination of the forearm. It is rare over the age of 5 to suffer a pulled elbow. A 6 year old should have 3 ossification centres – capitellum, radius, medial epicondyle. These x-rays confirm these are present. A child over the age of 5 year old should not have the medial epicondyle visible on an adequate lateral x-ray. An adequate lateral x-ray should have the ‘hour glass’ sign visible at the lower end of the humerus. These xrays suggest the medial epicondyle is posteriorly displaced, but the view is NOT an adequate lateral as the hourglass is absent. Normally on a lateral view of the elbow flexed in 90° a fat pad is seen on the anterior aspect of the joint. This is normal fat located in the joint capsule. Normallyon the posterior side no fat pad is seen since the posterior fat is located within the deep intercondylar fossa. Distention of the joint with blood from an injury will cause the anterior fat pad to become elevated and/or the posterior fat pad to become visible. An elevated anterior lucency and/or a visible posterior lucency on a true lateral radiographof an elbow flexed at 90° is described as a positive fat pad sign. This patient does not have a true lateral, so it is difficult to comment. Below is a true lateral Xray demonstrating 1. ‘Hour glass’ sign at distal end humerus. 2. Pathological anterior fat pad (enlarged, ‘Sail sign’) 3. Posterior fat pad (usually not present). 4. Breach in anterior cortex of distal humerus. 5. Posterior angulation of distal humerus. 6. Appropriate hidden position of medial epicondyle.

20. That is with an adequate lateral there are a number of true pathological signs consistent with a supracondylar fracture, and the loss of a false +ve medial epicondyle displacement.

21. Case Study which reinforce recommendations of CEC Septic Shock 4 Cognitive errors Triage errors Momentum Source: CDRS (Cognitive Dispositions To Respond) (Profiles In Patient Safety:”A Perfect Storm” in the Emergency Department (Samuel G.Campbell,Pat Croskerry,William Bond:Academic Emergency Medicine 2007) can steer a physicians cognitive processes and provide impediments to patient safety and need to be managed within the context of working on a busy ED shift.

22. Case Study which reinforce recommendations of Safety & Governance Committees In 2009, the Clinical Excellence Commission published a Clinical focus Report after a review of IIMs NSW data showed 167 incidents in 18 months. As a result of this report, the CEC joined the ECI (Emergency Care Institute) and the agency for Clinical Innovation in developing the sepsis pathway. See link for further resources to the sepsis pathway www.cec.health.nsw.gov.au/programs/sepsis. www.cec.health.nsw.gov.au/programs/sepsis

23. 60 doctors have started the course Completed: 38 (63.3%) Still Working through: 5 (8.3%) Off track – unlikely to complete: 17 (28.3%) Evaluation – Completion (defined by answering each case study correctly twice)

24. Strongly Agree / Agree Neutral Disagree / Strongly Disagree The HSP Spaced Education / WEDG course was effective in reinforcing educational objectives previously taught to me during the Hospital Skills Program workshop days 91.6%8.3%0.0% I believe the Spaced Education / WEDG course has changed my approach to how I practice as an ED Doctor 75.0%16.7%8.3% The Spaced Education course was effective as a method to learn or reinforce key knowledge points of Emergency Department diagnosis and treatment 91.7%8.3%0.0% I found the Spaced Education course enjoyable91.7%8.3%0.0% Context

25. Q. There are many forms of internet-based learning or e-learning. How does Spaced Education compare to other e-learning techniques? 1) Short Online Quizzes Strongly prefer / prefer Spaced Ed Neutral Prefer / Strongly prefer Online Quizzes Unsure 58.4%25.0%16.7%0.0% 2) Webinars Strongly prefer / prefer Spaced Ed Neutral Prefer / Strongly prefer Webinars Unsure 58.4%33.3%0.0%8.3% 3) Online Case-Based Discussion Forums Strongly prefer / prefer Spaced Ed Neutral Prefer / Strongly prefer online case-based discussion forums Unsure 66.6%16.7%0.0%16.7% Q. I would like to undertake other health related programs if offered in the Spaced Education format Strongly AgreeAgreeNeutral Disagree / Strongly Disagree 50.0% 0.0%

26. Evidence

27. Questions

28. Qstream Free Public Site app.qstream.com (Formerly Spaced Education) Enterprise sites

29. Qstream creation

30. Creating a Qstream Course Simple to create a quick Qstream course BUT… Creating an interesting, engaging and useful eLearning experience is never simple Relevance Levels of learning – remembering vs understanding vs analysing … (Bloom’s Taxonomy) Good Multiple Choice Questions Media – images, videos, sounds …

31. Questions