Diagnosis and management of acute kidney injury: deficiencies in the knowledge base of non-specialist, trainee medical staff

Background

Acute kidney injury (AKI) is common,¹ dangerous^2–6 and expensive.⁷ Survivors of the initial episode may have higher long-term mortality^8–10 and persistent – and potentially progressive – renal dysfunction.^6,9,10 However, AKI is potentially preventable in those at risk¹¹ – for instance, by avoidance of nephrotoxins and careful fluid management. In those who actually develop AKI, the severity of disease and its sequelae may be mitigated by early recognition and prompt institution of remedial measures.

Unfortunately, practice remains short of the ideal. A number of publications have described deficiencies in both clinical^12,13 and organisational^13–15 management in the UK alone. The most comprehensive of these assessments was undertaken by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)¹³ – an independent body that aims to optimise patient care through research and surveys of practice. One of a number of recommendations from NCEPOD was the need to enhance understanding of AKI among non-specialists. However, the extent of any gaps in knowledge has not been fully defined. With this in mind, we assessed the knowledge base of non-specialist, trainee medical staff within the catchment area of our regional renal unit.

Discussion

Most AKI is caused by ischaemia, sepsis and/or nephrotoxicity¹⁸ and so has the potential to be prevented as long as ‘at-risk’ patients are recognised. Even when AKI has developed, its severity and duration may be ameliorated through prompt treatment of the initiating condition and avoidance of further insults.

Unfortunately, the NCEPOD report,¹³ which confirmed previous evidence,¹² found that one-fifth of post-admission AKI was predictable and avoidable. Common findings included a failure to recognise unwell patients, infrequent blood monitoring and omissions in even basic fluid management. The NCEPOD report also found systematic delays in diagnosis and initial management, in part due to a straightforward failure to appreciate the significance of available data. Both NCEPOD¹³ and others¹² reported delays in seeking specialist advice.

Routine nephrological input into the care of patients with AKI is not realistic – geography and limited resources prevent expert review in most such cases. At the heart of NCEPOD's recommendations, therefore, was a need to enhance non-specialist understanding and awareness of the prevention and management of AKI. However, the NCEPOD report was not clear on whether poor practice was due to gaps in basic knowledge or whether other, more insidious, problems might have been at play. As an example, a statutory reduction in working hours has led to an increase in shift work and may have disrupted the continuity of care previously engendered within traditional team-based practice. Furthermore, lack of attention to detail may not have been due to poor understanding but due to AKI being given a low priority amidst numerous other demands; the expectations of more senior, non-specialist clinicians might have compounded the problem.

Our educational survey was undertaken to assess the scale of any knowledge deficits among those clinicians most likely to be involved in the initial stages of preventing and managing AKI. Our results confirmed serious gaps in understanding of AKI. This was evident across the grades; although, as might be anticipated, senior trainees scored higher. No differences were seen between trainees from the trust and the catchment area. As shown in Table 2, trainees scored highest when categorising AKI, but worrying deficiencies in this most basic of areas were still evident. In terms of educational experience, high proportions of trainees reported never having received any teaching on AKI. As might have been expected, specialty trainees were more likely to have received postgraduate teaching. Unexpectedly, significantly more specialty than foundation trainees reported that they had not had any undergraduate teaching on AKI. Clearly these apparent deficiencies in our teaching programmes are extremely concerning and warrant further examination.

It could have been argued that new terminology might have affected perceptions of actual educational experience. Arguing against this was the fact that most trainees were able to categorise AKI fully (median score = maximum score for that question; see Table 2), which suggests that there was no widespread confusion about nomenclature. In terms of actual teaching delivered, within the four years prior to the survey, we had given relevant talks to trust trainees on at least eight occasions and on one occasion for trainees at one of the catchment hospitals. Non-specialist trust trainees rotating through the renal unit (about 15 each year) also received teaching on AKI as part of their induction programme. An annual lecture on AKI is delivered to penultimate year undergraduates. In addition, all undergraduates receive teaching on recognition and initial management of the acutely unwell patient. The dichotomy between perceived and actual teaching experience highlights the pitfalls of self-reporting.

Our study also had other drawbacks. We did not collect data on self-directed learning, on the extent of any informal teaching or on the AKI component of ‘non-trust’ educational programmes. We also made an assumption that responses about teaching experience represented local provision, although most trainees do graduate locally. Our survey was not designed to assess organisational issues or to identify poor individual practice rather than poor understanding. Finally, and especially relevant to recent graduates, this snapshot survey was performed early in the annual academic cycle and so might not have captured teaching of AKI that was pending.

Addressing the identified knowledge deficits will require sustained educational efforts using a systematic approach that covers all key topic areas included in this survey. Furthermore, the questionnaire tool might be used as a template to quantify effectiveness. Organisational considerations include the priority and timing of educational sessions within already packed teaching programmes and how to free up extra time for those who might be expected to deliver these sessions. That these efforts might fail should at least be considered. Systematic aspects of working practice should be enhanced to target care of patients with AKI – for example, the detail of patient handover and the formalisation of risk assessment for AKI. Embedding care of patients with AKI within a regular, cross-organisational audit cycle might highlight areas of particular concern. Finally, innovative solutions, such as electronic clinical decision support systems, could be used to help protect patients from any remaining deficiencies in knowledge or practice.