An educational session with an easily reproducible simulation model improves trainee confidence with routine suprapubic catheter changes
BAUS ePoster online library. Henry M. 11/10/20; 304274; PCU-6
Ms. Mei-Ling Henry
Ms. Mei-Ling Henry
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An educational session with an easily reproducible simulation model improves trainee confidence with routine suprapubic catheter changes
Henry M-L 1, Sathanapally G 1, Williams S 1
1 Royal Derby Hospital, United Kingdom

Introduction
Suprapubic catheters (SPC) are common amongst NHS patients and routine catheter changes are usually required every 2-3 months. When a SPC is removed the tract may close after a short time. Therefore delays in reinsertion of a displaced or removed SPC may increase patient morbidity by necessitating further surgical procedures to dilate an existing tract or recreate a lost tract (Harrison et al 2010).
Routine SPC changes are frequently referred to on-call urologists in hospital. Many junior doctors report lack of confidence with suprapubic catheters and feel they have received inadequate training for catheterisation in general (Grimes et al 2019). Practical sessions on catheterisation have been shown to improve trainee confidence (Waters et al) and the use of anatomical models has been shown to increase confidence in new SPC insertion (Cetti et al). We found no literature on using models for routine SPC changes.
Aims
This project aimed to assess and improve junior doctor confidence in performing routine SPC changes in an established tract through use of simulation training.
Measures
Trainees completed a survey regarding their personal experience and confidence in catheterisation in general and in specific conditions. They provided self-rated confidence scores (on a scale of 1-5 where 1='Not very confident', 3='Neutral' and 5='Very confident') and repeated this directly after a teaching session. A multiple choice question regarding barriers to performing a routine SPC change was included. Post-course responses were compared to pre-course scores.
Changes
A training session was delivered comprising an interactive verbal presentation discussing technique, common misconceptions and troubleshooting advice. This was immediately followed by hands-on practice using simulation models where trainees were able to change a SPC with tactile feedback.
Methods
A cohort of 30 Foundation Year 2 (F2) doctors within a single hospital completed a survey regarding their experience and confidence in urethral and SPC immediately prior to the training session.

The models created simulated a SPC tract (Figure 1) using household sponge, a plastic box, silicon `practice tattoo skin` and a gallipot. Layers of household sponge sheets and silicon skin were cut to the dimensions of the plastic box lid to simulate the anterior abdominal wall and overlying skin in order to provide tactile feedback of mild resistance when inserting the catheter. A further household sponge was placed inside the plastic box to hold the gallipot in place. The gallipot was filled with water allow aspiration of fluid through a correctly placed catheter. A simulated SPC tract was created with use of a Seldinger SPC insertion kit. The models were tested by multiple urology middle grade doctors within the department in order to calibrate the models and verify the fidelity of simulation. These models were used as the basis for the practical skills element of the teaching session.

Trainees repeated the survey questions regarding confidence with routine SPC changes immediately after the training session. Responses were compared to pre-course scores.
Results
Of the 30 trainees who attended the teaching session, 28 completed both the pre-course and post-course questionnaires.
79% of trainees reported they had seen a patient with a SPC before (22/28). 29% of trainees had seen a routine SPC change before (8/28) and 14% of trainees had previously performed a routine SPC change themselves (4/28).

Pre-course Survey
The median self-reported confidence score selected by trainees was 4 for male urethral catheterisation and 3 for female urethral catheterisation. The median self-reported confidence score when performing a catheterisation in which other members of staff had failed was 2.
14% of trainees (4/28) reported that they would be willing to perform a routine SPC change for their patients or reinsert a displaced SPC, whereas 86% (24/28) stated they would not. The most commonly cited barriers were `lack of knowledge or skill` and `lack of confidence` which were selected 23 times and 21 times respectively. `I do not feel this is my responsibility` was selected 3 times and `other` was selected 3 times, with free text comments `Never been shown how to`, `fear of litigation` and `don't know equipment` cited as barriers. There was a statistically significant difference in willingness to perform an SPC change between trainees of varying experience in catheterisation in general (X2=16.4, p <0.001).

Post-course survey
Following the session, the median self-reported confidence score was 4 for performing a routine SPC change. 86% of trainees (24/28) reported they would be willing to perform a routine SPC change or reinsert a displaced SPC for their patients. A remaining 7% (2/28) reported they would not, citing `lack of confidence` as a barrier and another 7% of trainees (2/28) responded `sometimes` with no qualifying free text comment.
100% (28/28) of trainees felt the teaching session increased their confidence in performing a routine SPC change and that the simulation model was a useful tool in their learning.
Reassessment
Changes in trainee confidence were assessed by comparing pre-course and post-course survey responses and improvements were seen. Following the session, the median self-reported confidence score for SPC changes increased from 1 (not very confident) to 4 (mostly confident) and the number of trainees who reported they would be willing to perform a routine change of SPC for a patient increased from 14% (4/28) to 86% (24/28). 100% of trainees felt the simulation model was a useful tool and increased their confidence with the procedure (28/28).
Summary
Many junior doctors are report low confidence levels in routine SPC changes and would be unwilling to perform a routine change or reinsertion of a displaced SPC, therefore affecting patient care. Our survey results are in keeping with previous research (Grimes et al). Training with an easily reproducible simulation model improves junior doctor confidence and willingness to perform a routine SPC change in an established tract. This may result in fewer unnecessary on call referrals to urology or delays in patient care with regard to SPC changes.

References:1. Cetti R, Singh R, Bissell L, Shaw R. The urological foot soldier: are we equipping our foundation-year doctors?. The Bulletin of the Royal College of Surgeons of England. 2010;92(8):284-287.
2. Grimes N, Leask J, McKay A, McIlhenny C. Foundation Year 1 doctors' experience and confidence in catheterisation: A multicentre survey. Journal of Clinical Urology. 2019;12(5):380-384.
3. Harrison S, Lawrence W, Morley R, Pearce I, Taylor J. British Association of Urological Surgeons' suprapubic catheter practice guidelines. BJU International. 2010;107(1):77-85.
4. Hossack T, Chris B, Beer J, Thompson G. A Cost-effective, Easily Reproducible, Suprapubic Catheter Insertion Simulation Training Model. Urology. 2013;82(4):955-958.
5. Thomas A, Giri S, Meagher D, Creagh T. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital. BJU International. 2009;104(8):1109-1112.
6. Waters P, McVeigh T, Kelly B, Flaherty G, Devitt D, Barry K et al. The acquisition and retention of urinary catheterisation skills using surgical simulator devices: teaching method or student traits. BMC Medical Education. 2014;14(1).
An educational session with an easily reproducible simulation model improves trainee confidence with routine suprapubic catheter changes
Henry M-L 1, Sathanapally G 1, Williams S 1
1 Royal Derby Hospital, United Kingdom

Introduction
Suprapubic catheters (SPC) are common amongst NHS patients and routine catheter changes are usually required every 2-3 months. When a SPC is removed the tract may close after a short time. Therefore delays in reinsertion of a displaced or removed SPC may increase patient morbidity by necessitating further surgical procedures to dilate an existing tract or recreate a lost tract (Harrison et al 2010).
Routine SPC changes are frequently referred to on-call urologists in hospital. Many junior doctors report lack of confidence with suprapubic catheters and feel they have received inadequate training for catheterisation in general (Grimes et al 2019). Practical sessions on catheterisation have been shown to improve trainee confidence (Waters et al) and the use of anatomical models has been shown to increase confidence in new SPC insertion (Cetti et al). We found no literature on using models for routine SPC changes.
Aims
This project aimed to assess and improve junior doctor confidence in performing routine SPC changes in an established tract through use of simulation training.
Measures
Trainees completed a survey regarding their personal experience and confidence in catheterisation in general and in specific conditions. They provided self-rated confidence scores (on a scale of 1-5 where 1='Not very confident', 3='Neutral' and 5='Very confident') and repeated this directly after a teaching session. A multiple choice question regarding barriers to performing a routine SPC change was included. Post-course responses were compared to pre-course scores.
Changes
A training session was delivered comprising an interactive verbal presentation discussing technique, common misconceptions and troubleshooting advice. This was immediately followed by hands-on practice using simulation models where trainees were able to change a SPC with tactile feedback.
Methods
A cohort of 30 Foundation Year 2 (F2) doctors within a single hospital completed a survey regarding their experience and confidence in urethral and SPC immediately prior to the training session.

The models created simulated a SPC tract (Figure 1) using household sponge, a plastic box, silicon `practice tattoo skin` and a gallipot. Layers of household sponge sheets and silicon skin were cut to the dimensions of the plastic box lid to simulate the anterior abdominal wall and overlying skin in order to provide tactile feedback of mild resistance when inserting the catheter. A further household sponge was placed inside the plastic box to hold the gallipot in place. The gallipot was filled with water allow aspiration of fluid through a correctly placed catheter. A simulated SPC tract was created with use of a Seldinger SPC insertion kit. The models were tested by multiple urology middle grade doctors within the department in order to calibrate the models and verify the fidelity of simulation. These models were used as the basis for the practical skills element of the teaching session.

Trainees repeated the survey questions regarding confidence with routine SPC changes immediately after the training session. Responses were compared to pre-course scores.
Results
Of the 30 trainees who attended the teaching session, 28 completed both the pre-course and post-course questionnaires.
79% of trainees reported they had seen a patient with a SPC before (22/28). 29% of trainees had seen a routine SPC change before (8/28) and 14% of trainees had previously performed a routine SPC change themselves (4/28).

Pre-course Survey
The median self-reported confidence score selected by trainees was 4 for male urethral catheterisation and 3 for female urethral catheterisation. The median self-reported confidence score when performing a catheterisation in which other members of staff had failed was 2.
14% of trainees (4/28) reported that they would be willing to perform a routine SPC change for their patients or reinsert a displaced SPC, whereas 86% (24/28) stated they would not. The most commonly cited barriers were `lack of knowledge or skill` and `lack of confidence` which were selected 23 times and 21 times respectively. `I do not feel this is my responsibility` was selected 3 times and `other` was selected 3 times, with free text comments `Never been shown how to`, `fear of litigation` and `don't know equipment` cited as barriers. There was a statistically significant difference in willingness to perform an SPC change between trainees of varying experience in catheterisation in general (X2=16.4, p <0.001).

Post-course survey
Following the session, the median self-reported confidence score was 4 for performing a routine SPC change. 86% of trainees (24/28) reported they would be willing to perform a routine SPC change or reinsert a displaced SPC for their patients. A remaining 7% (2/28) reported they would not, citing `lack of confidence` as a barrier and another 7% of trainees (2/28) responded `sometimes` with no qualifying free text comment.
100% (28/28) of trainees felt the teaching session increased their confidence in performing a routine SPC change and that the simulation model was a useful tool in their learning.
Reassessment
Changes in trainee confidence were assessed by comparing pre-course and post-course survey responses and improvements were seen. Following the session, the median self-reported confidence score for SPC changes increased from 1 (not very confident) to 4 (mostly confident) and the number of trainees who reported they would be willing to perform a routine change of SPC for a patient increased from 14% (4/28) to 86% (24/28). 100% of trainees felt the simulation model was a useful tool and increased their confidence with the procedure (28/28).
Summary
Many junior doctors are report low confidence levels in routine SPC changes and would be unwilling to perform a routine change or reinsertion of a displaced SPC, therefore affecting patient care. Our survey results are in keeping with previous research (Grimes et al). Training with an easily reproducible simulation model improves junior doctor confidence and willingness to perform a routine SPC change in an established tract. This may result in fewer unnecessary on call referrals to urology or delays in patient care with regard to SPC changes.

References:1. Cetti R, Singh R, Bissell L, Shaw R. The urological foot soldier: are we equipping our foundation-year doctors?. The Bulletin of the Royal College of Surgeons of England. 2010;92(8):284-287.
2. Grimes N, Leask J, McKay A, McIlhenny C. Foundation Year 1 doctors' experience and confidence in catheterisation: A multicentre survey. Journal of Clinical Urology. 2019;12(5):380-384.
3. Harrison S, Lawrence W, Morley R, Pearce I, Taylor J. British Association of Urological Surgeons' suprapubic catheter practice guidelines. BJU International. 2010;107(1):77-85.
4. Hossack T, Chris B, Beer J, Thompson G. A Cost-effective, Easily Reproducible, Suprapubic Catheter Insertion Simulation Training Model. Urology. 2013;82(4):955-958.
5. Thomas A, Giri S, Meagher D, Creagh T. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital. BJU International. 2009;104(8):1109-1112.
6. Waters P, McVeigh T, Kelly B, Flaherty G, Devitt D, Barry K et al. The acquisition and retention of urinary catheterisation skills using surgical simulator devices: teaching method or student traits. BMC Medical Education. 2014;14(1).
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