Development and Delivery of an Acute Kidney Injury Education Program for Rural Healthcare Workers in Malawi

Introduction

Acute Kidney Injury (AKI) is common in low resource settings and leads to preventable deaths. 17.2% of general medical admissions in Malawi have confirmed AKI with an inpatient mortality of 41.8%. However, a recent survey of rural healthcare workers from across Southern Malawi found that 63% had never had any specific AKI teaching, 98% wanted more support in managing patients with renal disease and 55% did not know that haemodialysis was available in Malawi. The tertiary renal services at Queen Elizabeth Central Hospital in Southern Malawi comprises of a weekly outpatient clinic,a dedicated renal inpatient ward, a haemodialysis unit providing renal replacement for both acute and chronic kidney disease and acute peritoneal dialysis for children. Services are free at the point of delivery but despite this renal referrals from district hospitals are infrequent suggesting that renal disease in Malawi is under-diagnosed and under-treated.

Aims

  • To develop and deliver an AKI outreach education program for district healthcare workers in Malawi.
  • To raise awareness amongst district healthcare workers of tertiary renal services and the specialist support availableto them.
  • To educate regarding indications for referral and to increase the rates of referral of patients with AKI from district hospitals.

Method

All district hospitals in Southern Malawi were offered a half-day AKI teaching session delivered by a nephrology consultant or registrar. Prior to the teaching participants were surveyed on their experiences of AKI education. A PowerPoint presentation was given, focusing on the aetiology, diagnosis and management of AKI, followed by AKI case discussions. Participantsthen provided written feedback on the teaching. A new purpose-maderenal referral form, which includes a summary of indications for referral, was distributed with the aim of helping to increase the number ofreferrals.

Results

To date, 84 healthcare professionals in 4 of the 10government district hospitals have received AKI teaching. 62 attendees provided written feedback: 19 clinical officers, 9 medical officers, 30 nurses, and 4 with other roles within the multi-disciplinary team. Prior to training50% of attendees did not feel confident in managing AKI, 40% were not aware of the tertiary renal services, and only 15% had ever referred a patient with AKI. After the training, 89% felt their confidence in AKI diagnosis and management had improved, 94% were more aware of tertiary renal services, and 95% would be more likely to refer. Since the training, the renal team has received an increase in the number of telephone referrals and advice calls from an average of 2 calls every 3 months to 10 calls in the 3 months following the teaching.

Conclusion

Awareness and clinical experience of AKI diagnosis and management amongst rural healthcare workers in Malawi is limited. A rural AKI outreach education program resulted in increased confidence in AKI management and improved awareness of the tertiary renal services available. There has been an increase in the number of referrals from district hospitals, however we need more time to formally assess the longer-term impact of the training. We ultimately hope that this education intervention will help to reduce morbidity and mortality from AKI in Malawi. We would like to see this rural-based AKI training program serve as a model for developing further education programs across sub-Saharan Africa, as part of the initiative to reduce preventable deaths from AKI.