THU0595 The views and perceptions of non-specialist, hospital junior doctors on joint aspiration of the acute hot-swollen-joint, and their training in this clinical skill
Authors: Z Farah
Journal: Annals of the Rheumatic Diseases (2017)

<h3>Background</h3> BSR guidance on managing hot-swollen-joints recommends early joint aspiration (arthrocentesis) to rule out septic arthritis and avoid morbidity and mortality. In such patients, the initial assessment is often performed by junior doctors prior to specialist review. Previous audit suggests poor adherence to recommended guidance. Our previous quantitative survey in 2 hospitals found low self-reported confidence at managing hot-swollen-joints in 72 of 140 (52%) respondents; 58 (42%) participants reported inadequate exposure, and 43 (31%) inadequate training. There is limited research exploring the reasons behind poor uptake of arthrocentesis by junior doctors. <h3>Objectives</h3> To determine the perceptions of junior doctors about joint aspirations, their training to perform this important skill and how training could be improved <h3>Methods</h3> The focus group included two foundation doctors, two senior house-officers and two registrars. Focus group questions were developed from themes that emerged from our previous quantitative survey. The session was recorded using an iPhone, then anonymously transcribed verbatim. The transcript was analysed using an emergent coding technique drawn from grounded theory approach. The data was coded over three passes. <h3>Results</h3> Decision to aspirate a joint appeared to be influenced by internal and external factors. Internal factors included their previous experience, which was variable with one who <i>"did 7 aspirations"</i> and another who <i>"[had] not had any experience at all."</i> Other factors like anatomical knowledge, level of seniority and prior training were presented. Negative emotions emerged with participants using words like <i>"weary"</i>, <i>"anxious"</i> and <i>"scary"</i>, particularly <i>"fear of serious consequences"</i> when describing joint aspiration. External factors included procedure-related factors like technical difficulty, and the type of joint to be aspirated. Consensus suggested that all joints except the knee should be left to the specialist. Context-related factors included time constraints. The group emphasised the importance of recurrent exposure and opportunity to practice aspirations. Availability of supervision influenced the decision to aspirate, particularly if by the rheumatologist. Training in arthrocentesis appeared to be inconsistent. Positive comments included succinct dedicated training experiences by an expert using simulation, immediate feedback followed by practice. Negative comments emerged such as training was inconsistent and of poor timing, or trainees lacked the opportunity to subsequently practice. Participants then proposed methods of how to improve training in arthrocentesis. <h3>Conclusions</h3> The decision to aspirate is a complex interaction between internal and external factors combining knowledge, attitudes and emotions with circumstances and context. The participants emphasise training in knee aspirations, but not other joints due to lack of exposure. Immediate feedback during training in arthrocentesis is key. Inability to continue regularly practicing the procedure in real patients may be a barrier to retaining the skill. A review of training in joint aspiration may be required in order to improve uptake of this skill in practice. <h3>Disclosure of Interest</h3> None declared