Background and objectives Concerns have been raised about nephrology fellows' skills in inserting temporary hemodialysis catheters. Less is known about temporary hemodialysis catheter insertion skills of attending nephrologists supervising these procedures. The aim of this study was to compare baseline temporary hemodialysis catheter insertion skills of attending nephrologists with the skills of nephrology fellows before and after a simulation-based mastery learning (SBML) intervention.Design, setting, participants, & measurements This pre-post-intervention study with a pretest-only comparison group was conducted at the University of Toronto in September of 2014. Participants were nephrology fellows and attending nephrologists from three university-affiliated academic hospitals who underwent baseline assessment of internal jugular temporary hemodialysis catheter insertion skills using a central venous catheter simulator. Fellows subsequently completed an SBML intervention, including deliberate practice with the central venous catheter simulator. Fellows were expected to meet or exceed a minimum passing score at post-test. Fellows who did not meet the minimum passing score completed additional deliberate practice. Attending nephrologist and fellow baseline performance on the temporary hemodialysis catheter skills assessment was compared. Fellows' pre-and post-test temporary hemodialysis catheter insertion performance was compared to assess the effectiveness of SBML. The skills assessment was scored using a previously published 28-item checklist. The minimum passing score was set at 79% of checklist items correct.Results In total, 19 attending nephrologists and 20 nephrology fellows participated in the study. Mean attending nephrologist checklist scores (46.1%; SD=29.5%) were similar to baseline scores of fellows (41.1% items correct; SD=21.4%; P=0.55). Only two of 19 attending nephrologists (11%) met the minimum passing score at baseline. After SBML, fellows' mean post-test score improved to 91.3% (SD=6.9%; P,0.001). Median time between pre-and post-test was 24 hours.Conclusions Attending nephrologists' baseline temporary hemodialysis catheter insertion skills were highly variable and similar to nephrology fellows' skills, with only a small minority able to competently insert a temporary hemodialysis catheter. SBML was extremely effective for training fellows and should be considered for attending nephrologists who supervise temporary hemodialysis catheter insertions.

Background and Objectives: Survivors of acute kidney injury (AKI) are at higher risk of chronic kidney disease and death, but few patients see a nephrologist following hospital discharge. Our objectives during this 2-year vanguard phase were to determine the feasibility of randomizing survivors of AKI to early follow-up with a nephrologist or usual care, as well as to collect data on care processes and outcomes. Design, Setting, Participants, and Measurements: We performed a randomized controlled trial in patients hospitalized with Kidney Disease Improving Global Outcomes (KDIGO) stage 2-3 AKI at 4 hospitals in Toronto, Canada. We randomized patients to early nephrologist follow-up (standardized basket of care that emphasized blood pressure control, cardiovascular risk reduction, and medication safety) or usual care from July 2015 to June 2017. Feasibility outcomes included the proportion of eligible patients enrolled, seen by a nephrologist, and followed to 1-year. The primary clinical outcome was a major adverse kidney event at 1-year, defined as death, maintenance dialysis, or incident/progressive chronic kidney disease. Results: We screened 3687 participants from July 2015 to June 2017, of whom 269 were eligible. We randomized 71 (26%) patients (34 to nephrology follow-up and 37 to usual care). The primary reason stated for declining enrollment included hospitalization-related fatigue (n=65), reluctance to add more doctors to the healthcare team (n=59), and long travel times (n=40). Nephrologist visits occurred in 24/34 (71%) intervention participants compared to 3/37 (8%) randomized to usual care. The primary clinical outcome occurred in 15/34 (44%) patients in the nephrologist follow-up arm and 16/37 (43%) patients in the usual care arm (relative risk=1.02, 95% CI 0.60-1.73). Conclusions: Major adverse kidney events are common in AKI survivors, but we found that the in-person model of follow-up posed a variety of barriers that was not acceptable to many patients. (ClinicalTrials.gov, NCT02483039).