The Problem
Although umbilical catheterization can be a lifesaving technique in the emergent management of a critically ill neonate, it is performed infrequently in the ED.1 Simulation has emerged as a key teaching modality for residents to gain both proficiency and competency with this important procedure.2,3 Commercially available umbilical catheterization models are available, but costly, and often require an expensive investment (over $1,000 for a single trainer).4 This expense may discourage residency programs from acquiring the trainer and offering it to learners. In an effort to minimize this barrier to learning, a team from Kings County Hospital “home built” their own umbilical catheterization model. Their work was recently published in the Journal of Education and Teaching Emergency Medicine (JETem), and the ALiEM IDEA Series is proud to have recently teamed up with this journal to periodically share their innovations with our readership!
The Innovation
The low-cost task trainer for neonatal umbilical catheterization is easily constructed with readily available items found in the hospital, homes, and local home improvement and toy stores. An instructional session is held in small groups. Learners and facilitators review the indications, contraindications, and complications of umbilical catheterization. Facilitators perform a demonstration of the procedure, and then learners perform the procedure on the task trainer with facilitators providing real time feedback.
Figure 1. The simulator and some of the supplies required to perform the procedure including a laceration tray with instruments, scissors, pickups, and PVC umbilical vessel catheter.
This innovation was originally published in JETem in July, 2018.5 The full article can be accessed here.
Target Learners
Although EM residents were the targeted learner, providers at all stages of medical education, ranging from medical students to attending physicians. can receive instruction and practice on this task trainer. Moreover, the instructional session can be integrated into the training curricula of a variety of disciplines including pediatrics, neonatology, pediatric intensive care, and pediatric emergency medicine.
Group Size
The ideal ratio of learners to instructors is 4:1. Learners can be paired up in groups of 2 to take turns in the role of performing the procedure and assisting with supplies.
Materials Needed
| Item | Estimated Cost | Location to Obtain |
| Duck™ 20-in x 18-ft Taupe Shelf Liner | $13.00 | Home Improvement Store |
| 14Fr Suction Catheters | N/A | Hospital Supplies |
| Nasal Cannula Oxygen Tubing | N/A | Hospital Supplies |
| GE™ Silicone Clear Kitchen & Bath Caulk | $4.00 | Home Improvement Store |
| Gorilla™ Glue | $6.00 | Home Improvement Store |
| Nylon Cable Ties | $0.89 | Home Improvement Store |
| Painter’s Tape | $4.00 | Home Improvement Store |
| Industrial Clamps | $3.00 each | Home Improvement Store |
| Scalpel | N/A | Hospital Supplies |
| Plastic Toy Doll | $5.00 | Toy Store |
Description of the Innovation
The following pre-reading is recommended for faculty and learners:
- Sobolewski, B. Emergency Umbilical Venous Catheter Placement. Medical Resuscitation Committee at Cincinnati Children’s Hospital Medical Center. https://vimeo.com/35337127. Published January 19, 2012. Accessed April 1, 2018.
- Magnan JP, Rowe VL. Umbilical Vein Catheterization. Medscape Drugs & Diseases. https://emedicine.medscape.com/article/80469-overview. Published March 26, 2018. Accessed April 1, 2018.
- Dagle, J. Insertion of Umbilical Vessel Catheters. University of Iowa Stead Family Children’s Hospital. https://uichildrens.org/health-library/insertion-umbilical-vessel-catheters. Accessed April 1, 2018.
- Anderson J, Leonard D, Braner DA, Lai S, Tegtmeyer K. Umbilical Vascular Catheterization. New England Journal of Medicine. 2008;359(15).
Steps for constructing the low-cost task trainer for neonatal umbilical catheterization include the following:
Steps 1-3. Cut a 12 inch x 6 inch piece of shelf liner and lay it on a flat surface. Using cable ties, secure together 2 suction catheters and 1 single oxygen tubing at both ends. Lay the group of 3 tubes on the shelf liner and use industrial clamps to secure it at the ends to a flat surface.
Step 4. Apply Gorilla Glue to the shelf liner and to the tubes themselves (so as to glue them to each other). Allow this to dry for 2 hours. Once dry, cut the ends of the tubing distal to the cable ties.
Step 5. Apply silicone over the catheters and tubing.
Step 6. Roll the shelf liner into a log. Secure the log with painter’s tape and allow it to set for 24 hours.
Step 7. Remove the tape, and cut the log with a scalpel into 6” inch pieces.
Step 8. Using a commercially available plastic toy doll with a hollow abdomen, use a scalpel and cut a 1-inch circle into the abdomen.
Step 9. Insert the 6-inch section of cord into the cavity of the doll.The umbilical catheterization trainer is ready for use!
Steps for running the instructional session:
- Ask learners to review the pre-planning materials before the procedure session.
- At the start of the procedure session, facilitators assess learner readiness to perform the procedure by quizzing the group on its indications, contraindications, and complications.
- The faculty instructor demonstrates the procedure on the task trainer.
- The learner then performs the procedure independently. Faculty directly observe the learner and provide real time feedback. While observing the learner, faculty complete a checklist to help ensure that each individual step is mastered.
Outcomes Measured
This session was originally run with 40 EM resident learners. Although facilitators did not collect any data, anecdotal verbal feedback from participants was very positive. Many learners expressed increased comfort in performing the procedure and ease of use of the simulation trainer.
Lessons Learned
- This session is best implemented in smaller groups for hands-on sessions. This trainer and skill session was initially introduced to EM residents during a small group session led by Pediatric Emergency Medicine (PEM) fellows. The groups were 5 learners (EM residents ranging from PGY 1-4) to 1 instructor (PEM fellows, PGY 4-6). Groups of 4:1 would be better suited to use this model as the learners can pair up and take turns being the performer as well as the assistant.
- The task trainer was modified after the initial session to make the cord slimmer and thus more life-like. By using a range of catheter sizes (5-8 French) the learner is able to practice with larger (8 Fr) versus more delicate (5 Fr) catheters.
- By building the task trainer by hand, overhead costs are substantially reduced while still maintaining the anatomical and structural elements encountered in umbilical catheterization: mainly the identification of the vessels and the step by step approach to cannulation with securement of the catheter.
- Once built, these trainers can be reused many times, extending the ability to practice the procedure and to educate future learners.
- The trainer is lightweight and small. This allows makes it portable, and expands its use from small table top demonstrations in residency curricula to informal educational platforms in resource limited areas around the world.
Theory Behind the Innovation
Umbilical catheterization is an infrequently used, but potentially lifesaving technique in the management of a critically ill neonate. Given its infrequent nature, simulation is an effective method to introduce and teach learners this delicate procedure through deliberate practice. This refers to the notion that learners can master a skill through repeated, systematic, and focused attempts.6
Learners of all stages can practice the procedure with real time feedback, which may enable them to gain proficiency and competency.
Read more about the IDEA Series.
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