The barriers and facilitators to the design and delivery of sustainable healthcare across NHS Scotland: A forcefield analysis.

Healthcare systems around the world have set ambitious targets to design and deliver more environmentally sustainable healthcare. To achieve these targets, individuals, teams, organisations, and whole systems will have to change current attitudes, practices and processes. Change management theory advocates for early identification of the influencing forces to change, so that actions can be taken to overcome the barriers and strengthen the facilitators to increase the likelihood of success. This project undertook a forcefield analysis exercise to identify the barriers and facilitators to the design and delivery of sustainable healthcare in Scotland. The exercise identified 12 facilitators and 12 barriers to sustainable change and formulated ten recommendations to strengthen the former and overcome the latter. It is hoped that the results will raise awareness of the factors that influence the design and delivery of sustainable healthcare and will inform what actions can be taken to increase the likelihood of success.

Hypoxia-inducible factor prolyl hydroxylase inhibitors for anaemia in chronic kidney disease: a document by the European Renal Best Practice board of the European Renal Association.

Anaemia is a common complication of chronic kidney disease (CKD) and is associated with poor long-term outcomes and quality of life. The use of supplemental iron, erythropoiesis stimulating agents (ESAs) and blood transfusions has been the mainstay of treatment of anaemia in CKD for more than three decades. Despite available treatments, CKD patients with anaemia are undertreated and moderate-to-severe anaemia remains prevalent in the CKD population. Anaemia has consistently been associated with greater mortality, hospitalisation, cardiovascular events, and CKD progression in patients with CKD, and the risk increases with anaemia severity. Hypoxia-inducible factor (HIF) prolyl hydroxylase (PH) inhibitors have a novel mechanism of action by mimicking the body's response to hypoxia and have emerged as an alternative to ESAs for the treatment of anaemia in CKD. Their efficacy in correcting and maintaining haemoglobin has been demonstrated in over 30 phase 3 clinical trials. Additionally, HIF activation results in various pleiotropic effects beyond erythropoiesis with cholesterol reduction and improved iron homeostasis and potential anti-inflammatory effects. The long-term safety of these agents, particularly with respect to cardiovascular and thromboembolic events, and their possible effect on tumor growth requires to be fully elucidated. This document presents in detail the effects of HIF-PH inhibitors, describes their mechanisms of action and pharmacologic properties, and discusses their place in the treatment of anaemia in CKD according to the available evidence.

NEPHwork: creating a quality improvement and research network for UK renal trainees.

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.

"Is It Removed During Dialysis?"-Cognitive Dysfunction in Advanced Kidney Failure-A Review Article.

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.

Is there a need for formal undergraduate patient handover training and could an educational workshop effectively provide this? A proof-of-concept study in a Scottish Medical School.

BACKGROUND: Poor 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. OBJECTIVES: This 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. DESIGN: Students 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. SETTING: Medical education departments within National Health Service (NHS) Lanarkshire hospitals. PARTICIPANTS: Forty-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 MEASURES: Paired 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. RESULTS: Eighty-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. CONCLUSIONS: A 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.