P3D384: Using an Innovative Teaching Bundle to Improve Performance of the Infant Hip Exam

Purpose/Objectives: Developmental dysplasia of the hip (DDH) encompasses many common congenital hip malformations that can result in significant long-term sequelae if undiagnosed and untreated. The infant physical examination is a critical screening tool to identify infants at higher risk for DDH. However, there is reported variability in performance of the infant hip examination and low accuracy in examination technique. We aimed to determine if a new teaching bundle could improve the infant hip examination skills of pediatric interns across multiple pediatric residency programs.

Design/Methods: This multi-center prospective cohort study was conducted across 6 pediatric training programs in the Better Research for Newborns (BORN) Network. Pediatric interns who had previously been taught the hip exam in medical school were recruited from July - October 2022 for participation. All subjects underwent a baseline infant hip examination assessment using a checklist derived from textbook descriptions of the Galeazzi, Ortolani and Barlow maneuvers. Subjects demonstrated their exam skills on infant models designed to allow abduction, adduction and subluxation of the hips. Both a normal model and a model with positive signs for DDH were examined. After baseline assessment, all participants received a teaching bundle consisting of viewing a video of the correct hip exam, demonstration of correct hip maneuvers on both models by an expert, deconstruction of the skill into discreet steps, peer teaching and practice on the model, and execution of the skill without coaching. Final testing using the checklist was done by trained assessors not involved in examination instruction. All subjects filled out a post instruction survey. Data was analyzed using descriptive statistics.

Results: We enrolled 117 pediatric residents across 6 sites. Only 2% of participants (n=2) were able to identify a positive Galeazzi sign during the baseline assessment, while 88% (n=103, p< 0.001) were able to on post instructional assessment. While 27% of participants (n=32) correctly identified a positive Barlow sign on the baseline assessment, 69% (n=81, p< 0.001) did so on the post instructional assessment. The ability to correctly detect a positive Ortolani sign increased from 22% (n=26) to 92% (n=108, p< 0.001) between assessments. Using a Likert scale of 1-5 (1=not confident at all, 5=fully confident), confidence in performing the hip exam correctly increased from 2.2 (95% CI 2-2.4), to a mean of 4.0 (95% CI 4.0-4.2, p< 0.001) following instruction. Confidence in detecting abnormal findings on the hip exam increased from 1.8 (95% CI 1.6-1.9) to 3.8 (95% CI 3.6-3.9, p< 0.001). All subjects were able to correctly distinguish normal from abnormal hips after instruction.

Conclusion/Discussion: Most subjects in this study did not have accurate infant hip examination skills at entry into residency. A standardized teaching bundle significantly improved skills and confidence in performing a correct infant hip exam and identifying abnormalities.