Abstract
The Renal Expert in Vascular Access (REVAC) is one of the four modules of the Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) project, the first European-wide advanced training course in diagnostics and interventional nephrology, funded by Erasmus+ Knowledge Alliance, a European Commission program. The N-PATH primary goal was to train 40 young European nephrologists in both theoretical knowledge and practical skills related to interventional nephrology. The REVAC module focused on the crucial aspects of vascular access (VA) care in nephrology practice, as a complementary training path to the actual residency program. The aim was to provide nephrology fellows with comprehensive knowledge and skills related to VA management. The methodology was based on face-to-face meetings and online learning, modern facilities, experienced tutors, cutting edge simulators, augmented reality tools by means of a multidisciplinary international faculty and hands-on-courses. A feedback survey reported the experience of fellows who attended the REVAC module, confirming the positive impact on their ongoing nephrology training. We are confident that this project will revitalize their nephrology careers and will help training the next generation of nephrologists; they will be able to manage VA needs with the help of multi-disciplinary teams to safely optimize the care of hemodialysis patients.
Keywords
Introduction
The Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) project was the first European-wide advanced training course in diagnostics and interventional nephrology, funded by Erasmus+ Knowledge Alliance, a European Commission program (https://erasmus-plus.ec.europa.eu/). The primary goal was to train 40 young European nephrologists in both theoretical knowledge and practical skills related to interventional nephrology. N-PATH project (https://npath.eu/) is a consortium comprising eight Universities (Amsterdam University Medical Center, Università degli Studi di Bari Aldo Moro, Barcelona Parc Taulí Hospital Universitari, Ljubljana University Medical Center, Maastricht University Medical Center, Università degli Studi di Milano, University of Patras, and General University Hospital in Prague), two scientific societies (European Renal Association and Vascular Access Society), and two small enterprises (Eureka S.r.l. and EMAC S.r.l. Tcnologia Vitale; Figure 1). The program was structured in four curricular macro-topics: Renal Expert in Molecular Pathology (REMAP), Renal Expert in Vascular Access (REVAC); Renal Expert in Medical Ultrasound (REMUS); and Renal Expert in Peritoneal Dialysis (REPED).
The N-PATH consortium.
The REVAC module, within the N-PATH program, focused on the crucial aspects of vascular access (VA) care in nephrology practice, particularly for patients on dialysis. Nephrologists caring for patients with end-stage kidney disease spend a large portion of their time dealing with problems related to VA. Furthermore, VA-related issues significantly impact on the morbidity and mortality of patients but also on the costs incurred by the health care systems.1,2 In fact, VA-related complications and interventions account for almost one-third of hospital admissions among patients receiving HD. 3 The REVAC program aimed to equip nephrology fellows with comprehensive knowledge and skills related to VA management. Unfortunately, traditional nephrology fellowship education may not provide the skills needed to perform procedures safely, especially in this strategic area of nephrology; these procedures merely are listed as requisite, with no minimum standards for certification, although the certification and practice may differ throughout Europe. 4 Indeed, vascular access procedures can be considered as complex skills as they require an extensive practice and knowledge of human anatomy, physiology, and pathology.
A comprehensive coverage of dialysis VA has been part of the REVAC through a multidisciplinary educational path with a patient-centered approach focusing on interventional nephrology. The methodology was a blended learning approach, based on face-to-face meetings and online learning, modern facilities, experienced tutors, cutting edge simulators, and augmented reality tools by means of a multidisciplinary international faculty and hands-on-courses. This program can be seen as a stimulus for the next nephrology training programs to pay more attention to the procedural aspects of our profession, 5 but may also provide a training for all members of the VA team in the near future. We need to stimulate the appeal in nephrology among learners at European level to address the unmet need to provide high-quality services within European health system.
Learning objectives and the role of the tutor
The REVAC module was composed by three layers: web lectures, meet-the-expert sessions, and hands-on training. Each site involved, beside the assigned project responsible, recruited specialized teachers to build a multidisciplinary and international faculty who performed web lectures. An intuitive and personalized learning environment, a simple and user-friendly interface made the interaction with the e-learning platform as simple as possible. The main topics covered in VA field (Table 1) provided trainees with a strong background in different thematic areas, increasing the educational value of the meet-the-expert meeting and the hands-on training. To assess the effectiveness of the web lectures, trainees were required to take a test, composed of multiple-choice questions related to the lecture. The test was accessible only when the user visualized 100% of the lectures and, in case of failure, the user was able to repeat the test.
Web lectures included in the REVAC module.
Meet-the-expert sessions have been an opportunity for trainees to talk and interact with the teachers on the topics of their lectures, in which an innovative didactic approach, called “flipped classroom” was adopted. 6 Whereas the delivered on-line lectures became homework, the time spent during the interactive session (i.e. meet-the-expert) has been used for collaborative activities, sharing experiences and debate with the objective of capitalizing on individualized educational pathways and involvement of the residents. The sessions used live discussion to trigger active learning and to share impressions and ideas with peers and seniors. These sessions took place on Zoom (Zoom Video Communications, Inc. San Jose, CA, US) and have been organized by subject area: (1) VA planning, surgical techniques, surveillance; (2) central venous catheter; (3) AV graft, VA complications, and endovascular AVF.
The hands-on training courses took place in selected university hospitals involved in the project. Each site involved, beside the assigned project responsible, a group of qualified tutors in order to better assist the residents, and ensure direct support to maximize learning. In a 5- or 7-days hands-on course, depending on local organization, the trainees faced innovative simulators and real patients, learning how to perform a physical examination and how to make a strategy for the first and second access. They learned how to perform ultrasound (US) vascular mapping and choose the most appropriate artery and vein to construct an AV access. Beside the anatomy, they learned about surgical dissection and the main routes of the access to the arterial and venous system; how to choose the right VA site and type, aiming for a patient-specific approach. Trainees have understood the differences among different central venous catheter (CVC) types, identified the possible access sites for placement and have placed either non-tunneled or tunneled CVC in phantoms. They were involved in vibrant discussions on cases from “real world” practices and their outcomes. VA complications, and the most appropriate approaches to treat them were also discussed. Specific training was provided on VA monitoring and surveillance techniques, focused on ultrasound, and training on endovascular procedures for performing angioplasties and stent placement with simulators. Finally, patients’ eligibility for different techniques of endovascular VA creation was discussed.
The content and skills learned were organized around problems, rather than as a hierarchical list of topics, 7 and the core skill set was identified beforehand. Training was based on effective teaching; in other words, learning occurs through the demonstration of an act done properly to illustrate the process rather than by reviewing them, 8 and through the direct and deliberate practice that is the sequential, mindful repetition of a training task with feedback that leads to an effective improvement in performance.9,10 Tutors were facilitators, and not mere disseminators of knowledge, who supported and modeled reasoning processes, facilitated group processes and interpersonal dynamics, probed students’ knowledge deeply, and never interjected content or provided direct answers to questions. The context-specific nature of interventional nephrology necessitated that teachers open a dialog with learners about situational factors. The ultimate goal of this module was to provide knowledge about the multidisciplinary model of VA care, together with vascular surgeons, interventional radiologists, and nurses, in order to build a team that is able to meet any VA request in an effective, efficient, and safe manner.
Teaching aids
When appropriate, trainees faced real patients, especially for physical examination, pre-operative US vessel mapping, VA monitoring, and surveillance. Furthermore, throughout the hands-on and simulation-training a structured educational program offered a unique opportunity for safe practice and produced large and consistent improvement in trainees’ skills. 10 Arm simulators designed for the creation of vascular anastomosis allowed different kinds of arteriovenous fistulas and grafts to be created in multiple areas, and provided a realistic representation of the vascular anatomy and adjacent tissues. Different kinds of simulators and torso models with a vascular representation of the neck have also been used. These models allowed the introduction and placement of non-tunneled and tunneled central venous catheters with the use of the US. Simulators could be repeatedly punctured without causing deformities or leaks; models were composed of support and consumable elements that allow the trainee to reuse the phantom. Simulators for endovascular therapeutic procedures in arteriovenous fistulas for hemodialysis have also been used to practice endovascular interventions to dilate different-sized stenoses and place stents in the vascular bed of the arm and central venous trunks through three possible entry points for different devices. Procedures could be followed using cameras and computer screens simulating the endovascular intervention process. In addition, trainees were able to access the didactic content on a daily basis for developing skills in the strategic areas of nephrology. Virtual reality application containing the vascular bed of the upper extremity, with both arterial and venous structures, allowed the student to gain the 3D perspective and orientation of the anatomy. This helped to identify the most suitable areas for surgical creation of a fistula. The model could be studied with an ultrasound probe simulator, which aided understanding of how probe position could affect the visualization of the different structures.
Trainee satisfaction
Based on the REVAC feedback survey, filled by 38 and 37 residents (Tables 2 and 3), the majority of trainees (84.2%) indicated that their preliminary knowledge was sufficient for understanding and following the topics covered by the REVAC module. Some 90% considered the educational content adequate for understanding the topics covered in the exam, and 94.7% judged the teaching material as adequate for the study of the VA. For 78.9% of respondents, the meet-the-expert sessions met their expectations, and 97.3% declared the topics covered interesting (Table 2). Regarding the hands-on training course, 89.2% have declared they were very much satisfied with the event, and 97.3% considered the experience relevant and helpful for their careers. 86.5% considered that the teaching methods of the hands-on course fully met their expectations and 94.6% responded that their tutors were able to transfer all information needed. The mobility experience (logistic, transport, and accommodation) was judged positively by 89.2% of trainees (Table 3). Details on the REVAC feedback survey have also been reported (Supplemental Material). Active participation in the various training steps by using modern technologies (blended learning with the flipped classroom approach) guaranteed individual students to have a unique educational experience. Furthermore, a recent paper highlighted the experience of fellows who attended the REVAC hands-on training and its impact on their nephrology training. 11
REVAC module: feedback survey results from 95% (38/40) of respondents.
Details on the feedback survey are reported in the Supplemental Material.
REVAC Hands-on Training (HoT): feedback survey results from 92.5% (37/40) of respondents.
Details on the feedback survey are reported in the Supplemental Material.
Discussion
The main achievements of the REVAC module have been to (i) increase the knowledge on VA care, which is considered a strategic field to revitalize the nephrology career, and is one of the patient’s priorities in healthcare12,13; (ii) to improve procedural skills in interventional nephrology; (iii) to strengthen the awareness of the pivotal role of the nephrologist as a leader of a multi-disciplinary team to optimize the care for hemodialysis patients; (iv) to improve communication skills by establishing a collaborative network among all stakeholders involved in VA care. As reported in the trainees’ feedback survey, the quality and comprehensiveness of the training delivered during the REVAC module were beyond their expectations, considering the experience relevant for their careers. Therefore, the innovative educational model, practical training with skilled tutors and cutting-edge simulators enhanced clinical proficiency and fostered the development of expertise specific to the dialysis VA. The goal of the REVAC program was to provide trainees with a comprehensive knowledge and advanced skills related to the VA care, through a multidisciplinary educational path, and a patient-centric approach, where patient safety should be a must. REVAC has also created a strong collaborative network involving European medical schools, scientific societies and enterprises, to promote and develop a standardized core curriculum and disseminate knowledge through wider networks. As teachers and tutors, our role has been to stimulate the trainees’ curiosity on the challenges of VA management, providing tips on transitioning from fellowship into independent practice. The REVAC module, as well as the entire N-PATH program, can be seen as an opportunity for growth, innovation, and improved patient outcomes. As a proposal for the future, a memorandum of understanding already shared among the allied organizations of the N-PATH consortium has been signed, proposing this model as a possible training standard to revitalize nephrology careers across Europe.
Supplemental Material
sj-pdf-1-jva-10.1177_11297298241265163 – Supplemental material for Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) Erasmus+ project: The Renal Expert in Vascular Access (REVAC) module
Supplemental material, sj-pdf-1-jva-10.1177_11297298241265163 for Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) Erasmus+ project: The Renal Expert in Vascular Access (REVAC) module by Carlo Lomonte, Jose Ibeas, Panagiotis Kitrou, Antonio Giusto, Marta Baratto, Valentina Bocchibianchi, Giuliano Brunori, Nicola Pirozzi, Rafael Ponikvar, Giacomo Forneris, Jan Malik, Konstantinos Katsanos, Maarten Snoeijs, Matteo Tozzi, Maurizio Gallieni and Loreto Gesualdo in The Journal of Vascular Access
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project has received funding from the Erasmus+ Program of the European Union under grant agreement No 621385-EPP-1-2020-1-IT-EPPKA2-KA.
Ethical approval and consent to participate
This article is the report of an advanced training course at European level on aspects of vascular access care in nephrology practice. The consent to participate is not applicable.
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Supplemental material
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References
Supplementary Material
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