Medical Floor Research Articles

Glycemic Control and Outcomes of Hospitalization in Noncritically Ill Patients With Type 2 Diabetes Admitted With Cardiac Problems or Infections

Although the importance of glycemic control is well established for patients with diabetes hospitalized for surgical problems, it has not been supported by clinical studies for patients with diabetes hospitalized on the medical floors. We conducted a retrospective study of 378 patients with type 2 diabetes admitted for cardiac or infectious disease (ID) diagnosis between September 1, 2011, and August 1, 2012. Exclusion criteria included type 1 diabetes, admission to the intensive care unit (ICU), hospital stay shorter than 3 days, and daily glucocorticoid dose >20 mg of methylprednisolone. The primary composite outcome included death during hospitalization, ICU transfer, initiation of enteral or parenteral nutrition, line infection, deep vein thrombosis, pulmonary embolism, rise in plasma creatinine by 1 or >2 mg/dL, new infection, an infection lasting for more than 20 days, and readmission within 30 days and between 1 and 10 months after discharge. Patients were stratified by mean blood glucose (BG) level: group 1 had mean BG of <180 mg/dL (n = 286; mean BG, 142 ± 23 mg/dL), whereas group 2 had mean BG levels >181 mg/dL (n = 92; mean BG, 218 ± 34 mg/dL; P<.0001). Group 2 had a 46% higher occurrence of the primary outcome (P<.0004). The rate of unfavorable events was greater in cardiac and ID patients with worse glycemic control (group 2). Our data strongly support a positive influence of better glycemic control (average glycemia <180 mg/dL or 10 mmol/L) on outcomes of hospitalization in patients with type 2 diabetes.

Characterization of cleaning and disinfecting tasks and product use among hospital occupations.

Healthcare workers have an elevated prevalence of asthma and related symptoms associated with the use of cleaning/disinfecting products. The objective of this study was to identify and characterize cleaning/disinfecting tasks and products used among hospital occupations. Workers from 14 occupations at five hospitals were monitored for 216 shifts, and work tasks and products used were recorded at five-minute intervals. The major chemical constituents of each product were identified from safety data sheets. Cleaning and disinfecting tasks were performed with a high frequency at least once per shift in many occupations. Medical equipment preparers, housekeepers, floor strippers/waxers, and endoscopy technicians spent on average 108-177 min/shift performing cleaning/disinfecting tasks. Many occupations used products containing amines and quaternary ammonium compounds for >100 min/shift. This analysis demonstrates that many occupations besides housekeeping incur exposures to cleaning/disinfecting products, albeit for different durations and using products containing different chemicals.

Sleep Quality in Patients Admitted to the General Medical Floors

Sleep Quality in Patients Admitted to the General Medical Floors

Gastric Diverticuli as a Cause of Obscure Gastrointestinal Bleeding

Introduction: Gastric diverticuli are a rare but life-threatening source of obscure gastrointestinal bleeding. Their insidious and sometimes catastrophic presentation underlies the need for increased awareness and prompt management. A 75-year-old white male presented with symptoms of pre-syncope and dyspnea on exertion after multiple episodes of melena. He denied hematemesis, abdominal pain, dysphagia, or NSAID use. His co-morbidities included hypertension, diabetes mellitus, and atrial fibrillation. On admission, he was hemodynamically unstable with a tachycardia of 120 beats/minute and systolic BP of 60 mm of Hg. His physical examination was remarkable for melena on digital rectal examination. Laboratory tests revealed a Hb of 6.2, INR of 5.7, and an elevated BUN of 71. He was administered intravenous fluids, large-volume blood and plasma transfusions, and started on a pantoprazole infusion. On transfer to the ICU, he underwent an emergent upper endoscopy (EGD) with a large amount of retained blood and no obvious source of bleeding seen. The fundus was not adequately visualized due to an inability to clear the blood clots. An emergent Nuclear Medicine bleeding scan did not reveal active blood loss. He remained transfusiondependent and subsequently underwent a second EGD. This revealed the presence of a gastric fundal diverticulum (Figure 1 a,b), about 1 cm in diameter, with no other source of bleeding identified. The patient was referred for surgical evaluation; however, his clinical status gradually improved and he was discharged to the medical floor. Due to an often dramatic and potentially fatal presentation, gastrointestinal bleeding secondary to gastric diverticuli (GD) requires a high index of suspicion. Some reports have indicated vague symptoms of burning sub sternal pain or nonspecific abdominal discomfort preceding the presentation; however, patients are mostly symptom free. Prevalence ranges from 0.04% on barium contrast studies to 0.01-0.11% on endoscopy. Surgical resection is advocated in the presence of persistent symptoms or with complications such as persistent bleeding or a perforation.Figure 1

TF-12 Critical Actions in Common Floor Emergencies: A Multi-Disciplinary, Multimodality Course for Incoming First Year Residents

TF-12 Critical Actions in Common Floor Emergencies: A Multi-Disciplinary, Multimodality Course for Incoming First Year Residents

Is There A “July Effect” for Inpatient Glycemic Control?

ObjectiveThe period of resident turnover in teaching hospitals is considered by some to worsen health outcomes and is called the “July effect.” We sought to study glycemic control in patients admitted to medical floors and identify any adverse outcomes related to a “July effect.” MethodsThis was a single-center retrospective cohort study that compared inpatient glycemic control at the start and end of a single academic year (July 2009 to June 2010). A total of 108 patients with a diagnosis of diabetes mellitus were included in the first group (Group 1: July to September 2009), and 134 were in the second group (Group 2: April to June 2010). Four capillary blood glucose measurements were taken from Days 2 to 6 of hospitalization, and clinical data pertinent to glycemic management were collected. ResultsData analysis showed no significant difference in the overall inpatient glycemic control between the 2 groups. The mean glucose levels were 168.67 mg/dL and 168.59 mg/dL for Groups 1 and 2, respectively. Overall, 67% of patients in Group 1 and 72.9% in Group 2 were within a blood glucose range of 70 to 179 mg/dL, and 32% of patients in Group 1 and 44.1% of patients in Group 2 were within the range of 140 to 179 mg/dL. Hypoglycemia occurred in 17% and 18.6% of Groups 1 and 2, respectively. No difference in diabetes treatment ordering practices of residents was detected. ConclusionThis study did not show any evidence to support the “July effect” on overall inpatient glycemic control. (Endocr Pract. 2014;20:919-924)

Predictors of Outcome in Angiotensin Converting‐Enzyme Inhibitor‐Induced Angioedema

Objectives: (1) Identify high-risk symptoms and anatomical regions involved in Angiotensin Converting-Enzyme Inhibitor-Induced Angioedema (AIIA) that may affect admission and placement, hospital length of stay, need for airway intervention, and clinical improvement versus deterioration. (2) Describe a clinical algorithm for the management and treatment of AIIA that would dictate placement of patients (ICU, general medical floor, observation unit, or discharge home), medical therapy, and the need for airway intervention (intubation or tracheostomy). Methods: A retrospective chart review of adult patients presenting to the emergency department (ED) at Detroit Medical Center diagnosed with AIIA from July 2010 to July 2013. Patients were followed from initial presentation until discharge. Descriptive statistics (frequency, means, and standard deviations) were calculated for all predictor, outcome, and control variables. Results: A total of 302 patients who were diagnosed with AIIA in the ED were evaluated with flexible laryngoscopy by an otolaryngologist. A total of 94% of patients were African American, with a slight female predominance of 63%. The most frequent presenting sign was lip swelling (62%). Angioedema confined to the lips was a negative predictor for airway intervention ( P &lt; .01). Also, patients with isolated lip swelling were less likely to have progression of symptoms ( P &lt; .05), and were less likely to require ICU monitoring ( P &lt; .05). Conclusion: This is the largest patient series to date of AIIA. Using the information from this study, a clinical algorithm was developed that details management of AIIA based on presenting signs and anatomic location, with otolaryngologists playing a vital role in the decision making process.

Medical and neurologic complications of the current management strategy of angiographically negative nontraumatic subarachnoid hemorrhage patients

PurposeCommon management of angionegative subarachnoid hemorrhage includes mandatory intensive care unit stay for up to 14 days with strict bedrest, constant neurologic serial examination, invasive arterial and central line monitoring, and aneurysm rupture precautions. We evaluated the frequency of neurologic and nonneurologic complications in this patient population. MethodsThis was a retrospective chart review from July 2008 to 2011. Adult patients with International Classification of Diseases, Ninth Revision code for nontraumatic subarachnoid hemorrhage who had angiograms and cranial cat scans (CTs) were evaluated as the first screening measure. Negative screening angiograms constituted our study population and were divided into 2 groups (aneurysmal or perimesencephalic) based on the CT blood pattern. ResultsFifty-one patients met the study criteria (aneurysmal CT, n = 26; perimesencephalic CT pattern, n = 25). There were no incidences of rebleeding or mortality, and patients were discharged after a mean of 15.24 hospital days and a mean of 11 bedrest days. Seventeen patients (65%) in the aneurysmal group developed at least 1 nonneurologic complication compared with 2 patients (8%) in the perimesencephalic group (P = .001). Eleven patients in the aneurysmal group (42.3%) developed at least 1 neurologic complication compared with 1 patient (4%) in the perimesecephalic group (P = .001). ConclusionBased on our results, we propose admission to the medical floor for patients with World Federation of Neurosurgical Societies score 1 to 3, perimesencephalic CT pattern, and no hydrocephalus.

Automated detection of physiologic deterioration in hospitalized patients.

Develop and evaluate an automated case detection and response triggering system to monitor patients every 5 min and identify early signs of physiologic deterioration. A 2-year prospective, observational study at a large level 1 trauma center. All patients admitted to a 33-bed medical and oncology floor (A) and a 33-bed non-intensive care unit (ICU) surgical trauma floor (B) were monitored. During the intervention year, pager alerts of early physiologic deterioration were automatically sent to charge nurses along with access to a graphical point-of-care web page to facilitate patient evaluation. Nurses reported the positive predictive value of alerts was 91-100% depending on erroneous data presence. Unit A patients were significantly older and had significantly more comorbidities than unit B patients. During the intervention year, unit A patients had a significant increase in length of stay, more transfers to ICU (p = 0.23), and significantly more medical emergency team (MET) calls (p = 0.0008), and significantly fewer died (p = 0.044) compared to the pre-intervention year. No significant differences were found on unit B. We monitored patients every 5 min and provided automated pages of early physiologic deterioration. This before-after study found a significant increase in MET calls and a significant decrease in mortality only in the unit with older patients with multiple comorbidities, and thus further study is warranted to detect potential confounding. Moreover, nurses reported the graphical alerts provided information needed to quickly evaluate patients, and they felt more confident about their assessment and more comfortable requesting help.

Is There a "July Effect" for Inpatient Glycemic Control?

The period of resident turnover in teaching hospitals has been believed by some to lead to worsening of health outcomes or the so-called "July Effect". We sought to study glycemic control in patients admitted to medical floors looking for any adverse outcomes related to a"July effect". This is a single-center retrospective cohort study comparing inpatient glycemic control at the start and end of a single academic year (July 2009 to June 2010). A total of 100 inpatients with a diagnosis of diabetes mellitus were included in the first group (Group 1: July to September 2009) and 118 in the second group (Group 2: April to June 2010). Four capillary blood glucose measurements per day from Day 2 to Day 6 of hospitalization, as well as clinical data pertinent to glycemic management were collected. Data analysis showed no significant difference in the overall inpatient glycemic control between the two groups. Mean glucose for Group 1 was 168.67 mg/dL and 168.59 mg/dl for Group 2. 67% of patients in Group 1 and 72.9% in Group 2 were within blood glucose range of 70 - 179 mg/dl, 32% of patients in Group 1 and 52% of patients in Group 2 were within the range of 140 - 179 mg/dL. Hypoglycemia occurred in 17% and 18.6% of patients for Group 1 and 2 respectively. No difference in diabetes treatment ordering practices of residents was detected. This study did not show any evidence to support the "July Effect" on overall inpatient glycemic control.

Development of a hospital-based program focused on improving healthcare value.

Frontline physicians face increasing pressure to improve the quality of care they deliver while simultaneously decreasing healthcare costs. Although hospitals and physicians are beginning to implement initiatives targeting this new goal of healthcare value, few of them have a well-developed infrastructure to support this work. In March 2012, we launched a high-value care (HVC) program within the Division of Hospital Medicine at the University of California, San Francisco. The HVC program is co-led by a physician and the division's administrator, and includes other hospitalists, resident physicians, pharmacists, and administrators. The program aims to (1) use financial and clinical data to identify areas with clear evidence of waste in the hospital, (2) promote evidence-based interventions that improve both quality of care and value, and (3) pair interventions with evidence-based cost awareness education to drive culture change. We identified 6 ongoing projects during our first year. Preliminary data for our inaugural projects are encouraging. One initiative, which targeted decreasing nebulizer use on a high-acuity medical floor (often using metered-dose inhalers instead) led to a decrease in rates of more than 50%. The HVC program is proving to be a successful mechanism to promote improved healthcare value and clinician engagement.

An Unusual Case of Hematuria

A 66-year-old woman presented with acute onset of painless gross hematuria and generalized fatigue of 10 days’ duration. The patient was asymptomatic until she started to notice blood in her urine, not associated with dysuria or dribbling. Shortly afterward, she developed oliguria, and swelling of both legs, associated with mild exertional dyspnea, diffuse body aches, and fatigue without subjective fevers or chills. She had no oral or nasal ulcers, alopecia, photosensitivity, joint pain, joint swelling or redness, or symptoms of Raynaud’s phenomenon. She had mild exertional shortness of breath, but without chest pain or cough. She denied abdominal pain or any change in her bowel habits. Beside the gross hematuria, she denied any other urinary symptom. She denied weight loss, recent travels, or sick contacts. On evaluation in the emergency department, she was afebrile but hypertensive (blood pressure 188/98 mm Hg), which was a new symptom for her. She had periorbital edema as well as bilateral lower extremity pitting edema to the knees. Laboratory evaluation in the emergency room showed normocytic anemia, blood urea nitrogen of 44 mg/dl (normal range 7–18), and a creatinine level of 3.8 mg/dl (normal range 0.6–1.2). Her estimated creatinine clearance was 11.9 ml/minute/1.73 m (normal range 80–125) with a fractional excretion of sodium of 2.5%. Her creatinine was checked 3 weeks prior to admission during a routine checkup and found to be elevated at 1.4 mg/dl. She had a potassium level of 5.5 mEq/liter (normal range 3.5–5.1), a phosphorus level of 6.1 mg/dl (normal range 2.8–4.1), and a total calcium level of 8.2 mg/dl (normal range 8.4–10.2). Her urine analysis at presentation revealed 3 proteins, 3 blood, gross red blood cells (RBCs), 1–3 white blood cells, and trace leukocyte esterase. A chest radiograph performed on admission showed cardiomegaly with mild congestion. Kidney ultrasound did not show any hydronephrosis, kidney mass, or evidence of nephrolithiasis. She was admitted to the general medical floor with a diagnosis of acute kidney injury and nephrotic syndrome.

Ready, Set, Relax: Biofeedback-Assisted Relaxation Training (BART) in a Pediatric Psychiatry Consultation Service

Biofeedback-assisted relaxation training (BART) can treat several common pediatric presentations, including chronic pain and anxiety. Its effectiveness, applicability to a variety of conditions, and equipment portability make it an ideal treatment approach for use in an inpatient pediatric consultation-liaison service. Since there is a paucity of published research on the utility of BART in this setting, we studied pediatric patients (≥8y), medically-admitted to Boston Children's Hospital, and referred to the Psychiatry Consultation Service for assistance in managing pain, anxiety or both. The patients received at least 1 session of BART. In addition to heart rate variability and skin temperature data collection, participants completed the Wong-Baker FACES Pain Rating Scale and a brief mood/affective state rating scale (Youth Feelings Scale) before and after the BART sessions. A total of 152 sessions were conducted with 66 patients across 11 referring services. BART was successfully used 61% of the time on the medical floor with common barriers involving patient unavailability or refusal. The patients completed an average of 1.57 sessions per admission. The post-BART session pain and mood ratings significantly improved over the presession ratings. Patients with both pain and anxiety reported the greatest changes across sessions in comparison with those with only pain or anxiety. Higher heart rate variability was observed in the "pain-only" group. The use of BART in a consultation-liaison setting demonstrates promising utility in working with patients with pain, anxiety, or a combination of symptoms. BART was well-received by patients with subjective reports of benefit across sessions.

The Effect of New Duty Hours on Resident Academic Performance and Adult Resuscitation Outcomes: Pepper DJ, Schweinfurth S, Herrin VE. Am J Med 2014;127:337–42.

The implementation of changes in resident duty hours by the Accreditation Council for Graduate Medical Education (ACGME) on July 1, 2011 necessitated changes in resident work schedules. The revision in duty-hours standards by the ACGME intends to promote patient safety while also improving resident wellness and reducing fatigue. In this retrospective cohort study conducted at a single academic hospital, authors compared outcomes for emergency resuscitations that occurred on the inpatient medical floors for the periods of July 2010 to June 2011 and July 2011 to June 2012.

Prevention of inpatient hypoglycemia with a real-time informatics alert.

Severe hypoglycemia (SH), defined as a blood glucose (BG) <40 mg/dL, is associated with an increased risk of adverse clinical outcomes in inpatients. To determine whether a predictive informatics hypoglycemia risk-alert supported by trained nurse responders would reduce the incidence of SH in our hospital. A 5-month prospective cohort intervention study. Acute care medical floors in a tertiary care academic hospital in St. Louis, Missouri. From 655 inpatients on designated medical floors with a BG of <90 mg/dL, 390 were identified as high risk for hypoglycemia by the alert system. The primary outcome was the incidence of SH occurring in high-risk intervention versus high-risk control patients. Secondary outcomes included: number of episodes of SH in all study patients, incidence of BG < 60 mg/dL and severe hyperglycemia with a BG >299 mg/dL, length of stay, transfer to a higher level of care, the frequency that high-risk patient's orders were changed in response to the alert-intervention process, and mortality. The alert process, when augmented by nurse-physician collaboration, resulted in a significant decrease by 68% in the rate of SH in alerted high-risk patients versus nonalerted high-risk patients (3.1% vs 9.7%, P = 0.012). Rates of hyperglycemia were similar on intervention and control floors at 28% each. There was no difference in mortality, length of stay, or patients requiring transfer to a higher level of care. A real-time predictive informatics-generated alert, when supported by trained nurse responders, significantly reduced inpatient SH.

Comparison of awareness about nephrology and kidney diseases amongst doctors in institutes with and without nephrology departments.

To compare the awareness about nephrology and kidney diseases in medical officers and postgraduate trainee doctors working in institutes with and without nephrology departments. This cross sectional study was conducted at Nephrology Department, Shalamar Hospital Lahore from 1(st) Jan to 31(st) Mar 2013. Doctors working on medical floor with more than one year experience after house job were included in the study. Each doctor was given questionnaire comprising of 28 questions. Two hundred and eleven doctors fulfilling the criteria were included in the study. Most of the doctors were male 150(71.1%). Knowledge had strong correlation with practice (p= 0.001). Knowledge regarding nephrology and chronic kidney disease (CKD) was found significantly different among doctors of different hospitals [(F=36.09, p=0.000). Practice regarding nephrology and chronic kidney disease (CKD) was found significantly different (F= 7.222, p=0.000)] among doctors of different hospitals of Lahore. Doctors working in the Shaikh Zayed Hospital (SZH), Lahore were having maximum score in the components of the knowledge and practice than other hospitals. Awareness of the Medical Officers and postgraduate doctors is poor regarding nephrology and kidney diseases. Doctors working in institutes with established nephrology services have better knowledge than other units. Working experience of doctors improve the practice significantly.

Reducing Central Line-associated Bloodstream Infections in a Medical Oncology Population Utilizing an Electronic Surveillance Program

Reducing Central Line Blood Stream Infections (CLABSI) outside of the Intensive care Unit (ICU) is a major focus for hospitals. Our hospital uses an electronic algorithm (Non-ICU Electronic Rate {NICER}) to apply National Healthcare Safety Network definitions. This information is instantly available to the Infection Preventionists (IP) to look for trends in any area of the hospital. In 2013, the IP identified an elevated CLABSI rate of 2.74 on the Medical Oncology floor.

The Three Axial Perineal Evaluation (TAPE) score: a new scoring system for comprehensive evaluation of pelvic floor function

Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented. A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score. There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse. The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management.

Boarding of pediatric psychiatric patients is a no-fly zone for value.

Evolving concepts about the interwoven nature of physical and mental health have slowly, but incompletely, chipped away at the “reductionistic anachronism of mind/body dualism”1 that has historically separated them. The article, “Impact of Boarding Pediatric Psychiatric Patients on a Medical Ward,” in this edition of Hospital Pediatrics , however, highlights a series of challenges in which a patient’s body occupies a medical bed, but the mind is not getting the therapy it needs. The authors describe how psychiatric patients boarding on a medical floor receive little of the care they need while incurring high costs. Psychiatric boarding, which delays treatment when patients are most vulnerable, directly compromises all domains of quality (including safety, effectiveness, efficiency, timeliness, patient-centeredness, and equity) and is far from the high-value care we seek to deliver. The root of the problem, which must be addressed to ameliorate the situation, is that mental health care is grossly underfunded, which has led to insufficient physical and professional capacity. Since the 1960s, an appropriate emphasis on deinstitutionalization has led to a reduction in the number of psychiatric beds. Yet despite a desire to shift to outpatient and …

KNOWLEDGE ATTITUDE AND PRACTICE (KAP)OF CHRONIC KIDNEYS DISEASE AMONG MEDICAL OFFICERS OF TEACHING HOSPITALS OF LAHORE

BSTRACT Objective: This study was conducted to determine the knowledge, attitude and practice (KAP) about kidney diseases among medical officers working in different hospitals of Lahore. Study Design: Cross sectional Study. Place and Duration of the study: Department of Nephrology, King Edward Medical University, Mayo Hospital, Lahore from 1st Jan 2013 to 31st March 2013. Methodology: Doctors working on the medical floors of different tertiary care teaching hospitals [Mayo Hospital (MH), Sir Ganga Ram Hospital (SGRH), Service Institute of Medical Sciences (SIMS), Fatima Memoral Hospitals (FMH), Lahore General Hospitals (LGH), Shalamar Hospital (SH), Jinnah hospital (JH)] of Lahore were included in the study. Each doctor was given a questionnaire comprising of 28 questions. Each participant was given 10-15 minutes for completing the questionnaire at the spot. Categorization of doctors according to the KAP score was done as poor ( 70%). Results: One hundred eighty five doctors participated in the study who fulfilled the criteria. In this study majority 134 (62.6%) of the doctors were not taught about nephrology during their graduation which was statistically significant. Most of the doctors either had some knowledge or didn't know about procedures done in nephrology. Majority of the doctors 208(97.2%) know that nephrology deals with medical diseases of the kidney which was statistically significant. Most of the doctors 138(64.5) feel that nephrology services are insufficient in their hospital. More than 90% doctors want that kidney diseases should be taught during MBBS curriculum and separate nephrology department should be established which was statistically significant. Most of the doctors don't know the management of hyperkalemia very well. About 90% of the doctors know that there are five stages of CKD. Majority of the doctors know that ACE inhibitors are used in hypertension and diabetic nephropathy. They also know that urine complete examination help in early detection of diabetic nephropathy which was statistically significant. Conclusion: Most of the doctors have poor to average knowledge and practice about kidney diseases. Most of the doctors think that nephrology services are insufficient in their hospitals and it must be taught during graduation. Separate nephrology department should be established for creating awareness about kidney diseases Key words: Kidney diseases, Knowledge, Attitude, Practice, Nephrology, Doctors.