Cognitive impairment is independently associated with kidney disease and increases in prevalence with declining kidney function. At the stage where kidney replacement therapy is required, with dialysis or transplantation, cognitive impairment is up to three times more common, and can present at a younger age. This is not a new phenomenon. The cognitive interactions of kidney disease are long recognized from historical accounts of uremic encephalopathy and so-called “dialysis dementia” to the more recent recognition of cognitive impairment in those undergoing kidney replacement therapy (KRT). The understanding of cognitive impairment as an extra-renal complication of kidney failure and effect of its treatments is a rapidly developing area of renal medicine. Multiple proposed mechanisms contribute to this burden. Advanced vascular aging, significant multi-morbidity, mood disorders, and sleep dysregulation are common in addition to the disease-specific effects of uremic toxins, chronic inflammation, and the effect of dialysis itself. The impact of cognitive impairment on people living with kidney disease is vast ranging from increased hospitalization and mortality to decreased quality of life and altered decision making. Assessment of cognition in patients attending for renal care could have benefits. However, in the context of a busy clinical service, a pragmatic approach to assessing cognitive function is necessary and requires consideration of the purpose of testing and resources available. Limited evidence exists to support treatments to mitigate the degree of cognitive impairment observed, but promising interventions include physical or cognitive exercise, alteration to the dialysis treatment and kidney transplantation. In this review we present the history of cognitive impairment in those with kidney failure, and the current understanding of the mechanisms, effects, and implications of impaired cognition. We provide a practical approach to clinical assessment and discuss evidence-supported treatments and future directions in this ever-expanding area which is pivotal to our patients' quality and quantity of life.
NEPHwork was established in 2020 as a renal specialty trainee-driven national quality improvement and research network with the aim of coupling the benefits of trainee-led collaboration with the rich data collection infrastructure established by the UK renal registry. NEPHwork was established to support the development, coordination and delivery of audit and research projects by renal trainees on a national scale. The first collaborative project centred on the compliance with care quality standards in managing acute kidney injury. The project enabled a large amount of data to be collected over a relatively short period of time and allowed comparison between renal units involved in contributing to the data. The initiation of the NEPHwork collaboration had to overcome delays and service pressure related to the COVID-19 pandemic. Furthermore, the method of linkage analysis used in the data collection and lack of cohesion with regional information technology (IT) services prevented trainees from certain regions from contributing to the project and this is a key priority for the next NEPHwork collaboration.
BackgroundPoor communication between healthcare professionals is recognised as accounting for a significant proportion of adverse patient outcomes. In the UK, the General Medical Council emphasises effective handover (handoff) as an essential outcome for medical graduates. Despite this, a significant proportion of medical schools do not teach the skill.ObjectivesThis study had two aims: (1) demonstrate a need for formal handover training through assessing the pre-existing knowledge, skills and attitudes of medical students and (2) study the effectiveness of a pilot educational handover workshop on improving confidence and competence in structured handover skills.DesignStudents underwent an Objective Structured Clinical Examination style handover competency assessment before and after attending a handover workshop underpinned by educational theory. Participants also completed questionnaires before and after the workshop. The tool used to measure competency was developed through a modified Delphi process.SettingMedical education departments within National Health Service (NHS) Lanarkshire hospitals.ParticipantsForty-two undergraduate medical students rotating through their medical and surgical placements within NHS Lanarkshire enrolled in the study. Forty-one students completed all aspects.Main outcome measuresPaired questionnaires, preworkshop and postworkshop, ascertained prior teaching and confidence in handover skills. The questionnaires also elicited the student’s views on the importance of handover and the potential effects on patient safety. The assessment tool measured competency over 12 domains.ResultsEighty-three per cent of participants reported no previous handover teaching. There was a significant improvement, p<0.0001, in confidence in delivering handovers after attending the workshop. Student performance in the handover competency assessment showed a significant improvement (p<0.05) in 10 out of the 12 measured handover competency domains.ConclusionsA simple, robust and reproducible intervention, underpinned by medical education theory, can significantly improve competence and confidence in medical handover. Further research is required to assess long-term outcomes as student’s transition from undergraduate to postgraduate training.
BackgroundObjective assessment of medical handover skills is challenging. This short communication will illustrate the use of a modified Delphi technique in utilising both clinicians and educationalists to produce a fair and robust tool to assess medical student competence in handover. MethodUsing three rounds in a reactive Delphi process, two case-specific assessment tools were formulated. Round two involved clinical experts to respond to pre-defined criteria set in round 1, rather than being invited to develop their own benchmarks. Round 3 saw medical educationalists identify the components that a student should be expected to hand over at their stage of training. ResultsFor Case 1, twenty-eight initial key handover components were refined down to eighteen which were then encompassed in the final Case 1 assessment tool.For Case 2, thirty-one initial components were refined down to seven key handover components. These were then used to populate the final Case 2 assessment tool. DiscussionThrough the survey of clinical and medical education experts, the modified Delphi process allows the formation of a standardised assessment for individual handover scenarios, whilst ensuring a reflection of current clinical best practice. It is however, time consuming and the final tool is not necessarily faultless, as it invariably affected by the experiences and opinions of the group members. Continual validity judgements in assessment standardisation are essential.
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