Entrustable Professional Activities

EPA 6: Acute kidney injury

EPA 6

Acute kidney injury

Assess and manage patients with acute kidney injury

This activity requires the ability to:

  • diagnose and stage the severity of acute kidney injury
  • investigate the cause of the acute kidney injury, with specific attention to reversible causes
  • monitor and manage changes in pH, electrolytes, uraemic solutes and toxins, and water balance
  • recognise the indications for kidney replacement therapy
  • prescribe management strategies to support kidney recovery and prevent further injury
  • describe the basic principles of prescribing continuous or intermittent kidney replacement therapy for acute kidney injury
  • plan for adverse long-term sequelae of acute kidney injury and ongoing surveillance management.

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • identify acute kidney injury using age-appropriate Kidney Disease Improving Global Outcomes (KDIGO) criteria, such as adult, paediatric, or neonatal criteria
  • recognise immediate life-threatening conditions, and deteriorating and critically unwell patients, and respond appropriately
  • select investigations that identify or exclude critical patients’ issues
  • systematically identify causes of acute deterioration in health status and levels of physical and cognitive functioning
  • proactively manage timely escalation or transitions of care
  • develop plans of multidisciplinary treatment, rehabilitation, and secondary prevention following acute events
  • provide clear and effective discharge summaries with recommendations for ongoing care
  • optimise medical management and acute kidney injury risk before, during, and after operations
  • prevent or manage complications and long-term implications of kidney disease
  • identify indications, timing, and suitable modality for initiation of kidney replacement
  • recognise the indications for kidney biopsy
  • recognise the risks of long-term sequelae of acute kidney injury and ensure appropriate review as clinically indicated

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • identify acute deteriorations in kidney function
  • recognise seriously unwell patients requiring immediate care
  • understand general medical principles of caring for patients with undifferentiated and undiagnosed conditions
  • identify potential causes of current deterioration, and comply with escalation protocols
  • facilitate initial tests to assist in the diagnosis and development of management plans for immediate treatment
  • document information to outline the rationale for clinical decisions and action plans
  • assess perioperative and periprocedural patients
  • outline the pathophysiology of acute kidney injury in different clinical scenarios
  • ascertain volume status and order fluids to optimise volume status and/or kidney recovery

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • communicate clearly with other team members, and coordinate efforts of multidisciplinary teams
  • use closed loop, clear communication with the healthcare team
  • facilitate early communication with patients9, families and/or carers, and healthcare team members to allow for shared decision making
  • negotiate realistic treatment goals, and determine and explain the expected prognosis and outcomes
  • employ communication strategies appropriate for younger patients or those with cognitive difficulties
  • explain the situation to patients in a sensitive and supportive manner, avoiding jargon and confirming their understanding
  • determine the level of health literacy of individual patients and level of understanding of agreed care decisions

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate communication skills to sufficiently support the function of multidisciplinary teams
  • determine patients’ understanding of their diseases and what they perceive as the most desirable goals of care

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use clinical information technology systems for conducting retrospective and prospective clinical audits of the incidence and outcomes of acute kidney injury
  • evaluate and explain the benefits and risks of kidney replacement therapy based on individual patients’ circumstances
  • analyse adverse incidents and sentinel events to identify system failures and contributing factors
  • identify evidence-based practice gaps using clinical indicators, and implement changes to improve patient outcomes
  • coordinate and encourage innovation, and objectively evaluate improvement initiatives for outcomes and sustainability

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • evaluate the quality of processes through well designed audits
  • recognise the risks and benefits of kidney replacement therapy
  • raise appropriate issues for review at morbidity and mortality meetings
  • evaluate the quality and safety processes implemented within the workplace, and identify gaps in their structure

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • demonstrate effective supervision skills and teaching methods adapted to the training’s context
  • encourage questioning among junior colleagues and students in response to unanswered clinical questions
  • seek guidance and feedback from health care teams to reflect on the encounter and to improve future patients’ care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • mentor and train others to enhance team effectiveness
  • provide constructive feedback to junior colleagues to contribute to improvements in individuals’ skills
  • coordinate and supervise junior colleagues from the emergency department and wards

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • select studies based on optimal trial design, freedom from bias, and precision of measurement
  • evaluate the value of treatments in terms of relative and absolute benefits, cost, potential patient harm, and feasibility
  • evaluate the applicability of results of clinical studies to the circumstances of individual patients, especially those with multiple comorbidities
  • specify research evidence to the needs of individual patients

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate efficient searching of literature databases to retrieve evidence
  • use information from credible sources to aid in decision making
  • refer to evidence-based clinical guidelines and protocols on acutely unwell patients
  • demonstrate an understanding of the limitations of the evidence and the challenges of applying research in daily practice

Cultural safety

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • negotiate care decisions in a culturally appropriate way by considering variation in family structures, cultures, religion, or belief systems
  • integrate culturally appropriate care of Aboriginal and Torres Strait Islander and Māori peoples into patients’ management
  • consider cultural, ethical, and religious values and beliefs in leading multidisciplinary teams

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • practise cultural competency appropriate for the community serviced
  • proactively identify barriers to access to health care

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • develop management plans that are based on medical assessments of the clinical conditions and multidisciplinary assessments of functional capacity
  • advise patients of their rights to refuse medical therapy, including life-sustaining treatment
  • consider the consequences of delivering treatment that is deemed futile, directing to other care as appropriate
  • facilitate interactions within multidisciplinary teams respecting values, encouraging involvement, and engaging all participants in decision making
  • demonstrate critical reflection on personal beliefs and attitudes, including how these may affect patient care and healthcare policy

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • communicate medical management plans as part of multidisciplinary plans
  • establish, where possible, patients’ wishes and preferences about care
  • contribute to building a productive culture within teams

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • recognise the need for escalation of care, and escalate to appropriate staff or service
  • integrate evidence related to questions of diagnosis, therapy, prognosis, risks, and causes into clinical decision making
  • reconcile conflicting advice from other specialties, applying judgement in making clinical decisions in the presence of uncertainty
  • use care pathways effectively, including identifying reasons for variations in care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • involve additional staff to assist in a timely fashion when required
  • recognise personal limitations, and seek help in an appropriate way when required

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • optimise team members’ skills and expertise in delivering patient care
  • involve the multidisciplinary kidney team, including:
    • dietitians
    • intensivists
    • nurse practitioners, with roles such as CKD, supportive care, anaemia access, and transplant
    • pharmacists
    • psychologists
    • social workers
  • manage the transition of acute medical patients through their hospital journeys
  • lead a team by providing engagement while maintaining a focus on outcomes
  • manage and escalate open disclosure

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • collaborate with and use other team members, based on their roles and skills
  • ensure appropriate multidisciplinary assessments and management
  • encourage an environment of openness and respect to lead effective teams

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • allocate resources responsibly, balancing costs against outcomes
  • prioritise patients’ care based on needs, considering available health care resources
  • collaborate with emergency medicine staff and other colleagues to develop policies and protocols for the investigation and management of common acute medical problems
  • recognise and apply local/national and international kidney guidelines including Caring for Australian and New Zealanders with Kidney Impairment (CARI) and KDIGO

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • explain the systems for the escalation of care for deteriorating patients
  • explain the role of clinician leadership and advocacy in appraising and redesigning systems of care that lead to better patient outcomes