Survey of non-tunneled temporary hemodialysis catheter clinical practice and training

Learning Curve for Temporary Hemodialysis Catheter Placement

BACKGROUND

Training is essential for the safe and uncomplicated placement of hemodialysis catheters. This study explores the learning curve of this procedure.

METHODS

In this prospective study, 60 patients who needed emergency hemodialysis without vascular access were included. All catheters were placed under ultrasound guidance. One nephrologist was included in each two groups, one to be consisted of a junior, and one to be consisted of a senior. Learning curves were created using the cumulative total methodology and receiver operating characteristic curve analyses.

RESULTS

The patients' mean age was 67.92 ± 14.23 years. The mean catheter insertion time of the senior nephrologist was significantly shorter than that of the junior. According to cumulative total analysis, the junior group's maximum learning point overlaps with patient 22. When the confidence intervals of the study durations of both groups were examined, they overlapped in the 95% confidence interval starting from the 19th patient. When the mean catheter insertion time of the senior and the mean of the last 12 patients of the junior were compared, there was no significant difference between them (F = 15.827, P = .092). The receiver operating characteristic curve analysis showed a cutoff value of 320 seconds for the junior group compared with the senior group, indicating an overlap in case 22 for the junior nephrologist.

CONCLUSION

This study suggests that 22 catheter insertions under the supervision of a senior nephrologist are needed to complete the learning curve for a junior nephrologist. If the number of nephrologists at the center is limited, safe catheter insertion may be allowed after 19 insertions.

Current Paradigms and Emerging Opportunities in Nephrology Training

Nephrology is facing a period of remarkable and unprecedented change. The pipeline of device and therapeutic drug development, the growing success of clinical trials, and the emergence of novel clinical practice and training pathways each hold the promise of transforming patient care. Nephrology is also at the forefront of health policy in the United States, given the recent Advancing American Kidney Health initiative. Despite these developments, significant barriers exist to ensure a robust pipeline of well-qualified nephrologists, including but not limited to trainees' declining trainee interest in the specialty, lower board pass rates, and a perceived erosion in stature of the subspecialty. There is a lack of consensus among training program directors regarding procedural training requirements, the number of fellowship positions needed, and the value of the match. There is widespread agreement, however, that any initiative to reassert the value of nephrology must include significant focus on reinvigorating the trainee experience before and during fellowship. We discuss the current state of education in nephrology (from medical school to beyond fellowship) and highlight ways to increase interest in nephrology to reinvigorate the specialty.

The Electronic Medical Record and Nephrology Fellowship Education in the United States: An Opinion Survey

BACKGROUND AND OBJECTIVES

An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons.

RESULTS

Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias.

CONCLUSIONS

Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.