Invited Manuscript Poster on Renal-Related Education American Society of Nephrology, Nov. 16–21, 2010 Do Medical Trainees Receive Adequate Training in the Management of Acute Kidney Injury?

Abstract

There has been increased interest in acute kidney injury (AKI) over the past decade following the recognition of the association of relatively small rises in serum creatinine with worse patient outcomes. This association has resulted in newly proposed definitions in AKI based on changes in serum creatinine. In 2009, the National Confidential Enquiry into Patient Outcomes and Death Adding Insult to Injury AKI study reported that only 50% of patients who died with a diagnosis of AKI received good care. The study identified multiple deficiencies and made a number of recommendations which included improving the training of undergraduate and postgraduate trainees in the management of AKI. The aim of the evaluation was to try and identify the perception of medical trainees in Leeds Teaching Hospitals of the training they had received on AKI. A simple questionnaire was used and captured the views of 73 trainees (including 13 final-year medical students). The evaluation indicated that the majority of trainees were unaware of newly proposed definitions of AKI, and many trainees felt that the training they had received in AKI was inadequate for their needs. Following this evaluation, we have made a number of changes to the training that is delivered to both undergraduate and postgraduate trainees in Leeds on the management of AKI.

Keywords:

• Acute kidney injury
• education
• NCEPOD
• trainees

INTRODUCTION

Acute kidney injury (AKI) has now replaced the term acute renal failure to better reflect that it represents a spectrum of disease with a range of underlying aetiologies.¹ Over the past few years, there have been attempts to establish a universal definition by the Acute Dialysis Quality Initiative (ADQI) group and the Acute Kidney Injury Network (AKIN).² Most recently, the international guideline development group, Kidney Diseases: Improving Global Outcomes (KDIGO), has devised a definition and staging system that harmonizes the proposed definitions from both ADQI and AKIN.³ The definition of AKI is based on rises in serum creatinine or reductions in urine output, which have been demonstrated to be associated with worse patient outcomes. It is hoped that the adoption of a universal definition for AKI will lead to improved recognition and earlier treatment of the disease. Currently there is a paucity of data describing the epidemiology of AKI in the United Kingdom and current estimates of its incidence are based on old definitions. AKI is a condition that commonly develops in acutely ill patients and therefore occurs across a wide range of medical and surgical specialties.⁴ Unfortunately, the recognition and management of patients with AKI has been poor with only 50% of patients receiving good care as reported in the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) Adding Insult to Injury AKI study.⁵ Poor recognition of AKI risk factors has further been identified in a more recent NCEPOD study Elective and Emergency Surgery in the Elderly: An Age-Old Problem.⁶ In both studies, there have been clear recommendations that there needs to be improvements in both undergraduate and postgraduate training in the recognition and management of AKI. As with any new initiative or guideline education is crucial to implementation. With this in mind, we decided to determine the knowledge gaps surrounding AKI that exist in both undergraduate and postgraduate medical trainees in Leeds.

Table 1. Trainee responses regarding adequacy of teaching they have received on AKI and comments on how this may be improved in the future.

	Adequate teaching	Inadequate teaching	Comments	Training needs identified
Undergraduate	6/13 (46.1%)	7/13 (53.9%)	Received a considerable amount of teaching in basic renal physiology in first-year medical school	More clinically relevant lectures Refresher sessions on AKI guidelines
			Difficult to translate lectures into clinical practice	Clinical teaching on fluid volume assessment and management
Postgraduate: Not all trainees responded	28/60 (47%)	19/60 (32%)	Very little training provided in the clinical management of AKI 13/60 (21%) refrained from answering the question	More renal placements
				Improved teaching on fluid balance assessment and management
				More AKI guidelines including when to refer to renal

AIM

The aim of the evaluation was to identify existing knowledge gaps in medical trainees’ understanding of AKI and consider how these gaps may be addressed in the future.

METHOD

It was decided that the question would be approached as a service evaluation of the teaching and training that had been previously received by the trainees in AKI. An anonymized simple questionnaire was given to trainees who attended a specific lecture on AKI that was delivered on two separate occasions as part of the postgraduate education training program in Leeds Teaching Hospitals. The trainees were asked to complete the relevant sections of the questionnaire prior to the lecture commencing and then following the lecture. This lecture was also open to final-year medical students to attend.

QUESTIONNAIRE

A simple questionnaire was given to all trainees that attended a lecture on AKI as part of the postgraduate training program. The trainees were invited to complete the appropriate sections of the questionnaire anonymously before and after the lecture. The questionnaire captured age, grade, and specialty of the respondent and asked the trainees a series of questions regarding their current understanding of AKI and the training they had received.

RESULTS

A total of 73 trainees completed the questionnaires, of which 38 were foundation-year trainees (equivalent to interns), 22 core medical trainees (equivalent to residents), and 13 final-year medical students. The final-year medical students attended as part of their shadowing program to prepare them for clinical practice following graduation. The median age of the trainees was 26 years. The majority of trainees were on medical placements (n = 41, 56%) and surgical placements (n = 29, 40%). The remaining three trainees were from the intensive care unit (ICU), accident and emergency (emergency medicine), and radiology.

Definition of Acute Kidney Injury

When asked to define AKI, 7 trainees cited the ADQI RIFLE, or the AKIN definitions, 26 trainees gave their own definition, and 40 trainees did not offer an answer.

Adequacy of Previous Teaching on Acute Kidney Injury and Comments on Perceived Training Needs

The trainees were asked to judge from their perspective whether the teaching they had been provided for throughout their training had been either adequate or inadequate. They were asked to comment on previous teaching and suggest how this might be improved in the future to meet their training needs (Table 1).

Which Books and Online Resources Are Most Commonly Used by Undergraduate and Postgraduate Trainees?

•	Oxford Handbook in Medicine (most popular resource)
•	British Medical Journal e-learning
•	Scottish Intercollegiate Guidelines
•	Local hospital protocols and guidelines

The trainees commented that they felt there was a paucity of local AKI guidelines which could potentially help them in the management of the disease process.

What Is the Effect of Experiencing a Renal Placement as an Undergraduate or Postgraduate Trainee?

The majority of trainees felt that a renal attachment or placement during their medical training provided a good opportunity to better understand how to manage AKI. Those trainees that had already completed a renal placement commented that they found it very helpful. It was also identified that an attachment or placement on the ICU provided a good learning experience with respect to the management of AKI. Trainees felt that time spent within both the renal unit and the ICU provided them with an increased level of confidence.

What Is the Trainee’s Perception of the Role of the General Physician in the Management of AKI?

The majority of trainees responded that general physicians need to be able to prevent and initiate treatment for AKI, requesting a renal referral at the appropriate time.

DISCUSSION

The aim of the evaluation was to assess the perception of medical trainees of the training they had received in the management of AKI. A simple questionnaire was used to help identify any knowledge gaps that existed in the learning of the trainees. It was probably not surprising that, given the recent NCEPOD Adding Insult to Injury AKI study,⁴ a number of deficiencies were raised by the trainees. Due to the timing of the lectures, we are fortunate to obtain the opinions of a small number of undergraduate medical students as well as postgraduate trainees. It was apparent that there was a lack of clarity over the newly proposed definitions of AKI that are now available in the literature. This poses the problem of when do trainees consider that they are dealing with a patient with AKI. The NCEPOD Adding Insult to Injury AKI study reported that there were delays in recognizing patients developing AKI following admission to hospital. It is hoped that the introduction of the international definition for AKI by the KDIGO guideline group will prompt trainees to recognize patients developing AKI at an earlier stage as indicated by defined rises in serum creatinine.

The majority of trainees commented on the fact that the training they had received in AKI as undergraduates and postgraduates had been inadequate and difficult to relate to patient management when faced with the clinical scenario. Trainees felt the general physicians should be able to identify and treat AKI, but also know when to refer to the renal team. The opportunity to train within a renal unit or on the ICU was identified as a positive experience providing the trainees with an increased confidence in their ability to manage AKI. This observation reinforces the concept that some of the clinical aspects of managing AKI including fluid management require experiential learning. This kind of practical learning cannot be taught in the lecture theatres. Many of the trainees prefer to use general medical handbooks rather than specialized textbooks to aid with the management of AKI. It was identified that there was a need to provide simple clear guidelines on the management of AKI locally.

Following this evaluation there has been an increased emphasis on AKI and fluid management within both the undergraduate and postgraduate curricula. Some further recommendations from this evaluation will include the following:

•	Undergraduate and postgraduate training in AKI needs to be made more clinically relevant.
•	There needs to be an increased awareness of the association of AKI with worse patient outcomes. AKI needs to be considered as an independent risk factor.
•	As assessment is intimately linked with learning; undergraduate and postgraduate exams need to include both written questions and clinical stations on AKI.
•	Local guidelines for the management of AKI should be made available electronically.
•	Continued development of e-learning modules in AKI.

The NCEPOD Adding Insult to Injury AKI report has provided a stimulus to improve AKI training in the United Kingdom and therefore ultimately improve patient care. There have been new national initiatives to provide electronic learning resources such as the Map of Medicine AKI pathway⁷ and the NHS Electronic Learning for Health initiative which is developing a number of e-learning modules in AKI for the general medical trainee.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.