title: Improving the diagnostic workup of hyponatremia in the setting of kidney disease: a continuing medical education (CME) initiative.
abstract: OBJECTIVE
  Hyponatremia is a common electrolyte disorder and is associated with mortality. We examined the frequency of appropriate testing in response to an episode of inpatient hyponatremia in a large urban hospital to better inform our educational intervention. We then evaluated the impact of a live CME activity with a focus on CKD- and ESRD-associated hyponatremia physiology, on diagnostic practices of audience hospitalist attendings.
  
  
  METHODS
  We performed a retrospective database analysis of all patients admitted to Montefiore Medical Center in 2014 to examine the performance of hospital staff in response to hyponatremia across all CKD stages. We then did a comparative analysis of diagnostic workup orders for hyponatremic patients admitted to audience members of a live CME activity in the 4 months prior as compared to the 4 months after the activity.
  
  
  RESULTS
  The prevalence of hyponatremia was 27% in a cohort of hospitalized patients: 41% of these hyponatremia inpatients had CKD, and 11.4% had ESRD. Overall less than 10% of patients had orders written for serum and urine osmolality without a differential pattern based on CKD or ESRD diagnosis. Among the patients admitted to the CME audience hospitalists, urine/serum osmolality and urine sodium orders occurred infrequently overall and did not differ after vs. before the lecture.
  
  
  CONCLUSIONS
  The frequency of appropriate diagnostic orders written in response to an episode of hyponatremia was very low and did not vary based on degree of CKD. A CME activity with an emphasis on the role of CKD/ESRD in diagnostic accuracy did not improve the order quality in a group of audience hospitalists. Efforts to improve the diagnostic workup of hyponatremia with concomitant kidney disease are crucial to proper management of these patients.
authors.affiliation: Montefiore Medical Center, Albert Einstein College of Medicine, 3450 Wayne AveSuite 5H, Bronx, NY, 10467, USA. lgolesta@montefiore.org.
authors.forename: Ladan
authors.initials: L
authors.lastname: Golestaneh
authors.affiliation: Montefiore Medical Center, Albert Einstein College of Medicine, 3450 Wayne AveSuite 5H, Bronx, NY, 10467, USA.
authors.forename: Joel
authors.initials: J
authors.lastname: Neugarten
authors.affiliation: Montefiore Medical Center, Albert Einstein College of Medicine, 3450 Wayne AveSuite 5H, Bronx, NY, 10467, USA.
authors.forename: William
authors.initials: W
authors.lastname: Southern
authors.affiliation: Montefiore Medical Center, Albert Einstein College of Medicine, 3450 Wayne AveSuite 5H, Bronx, NY, 10467, USA.
authors.forename: Faraj
authors.initials: F
authors.lastname: Kargoli
authors.affiliation: Montefiore Medical Center, Albert Einstein College of Medicine, 3450 Wayne AveSuite 5H, Bronx, NY, 10467, USA.
authors.forename: Amanda
authors.initials: A
authors.lastname: Raff
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004502:Education, Medical, Continuing; D005260:Female; D005919:Glomerular Filtration Rate; D019983:Guideline Adherence; D020445:Hospitalists / Q000193:education*; D006801:Humans; D007010:Hyponatremia / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology*; D065186:Interrupted Time Series Analysis; D007676:Kidney Failure, Chronic / Q000150:complications / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D009994:Osmolar Concentration; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D015397:Program Evaluation; D012720:Severity of Illness Index; D012964:Sodium / Q000097:blood / Q000652:urine
chemical_list: D012964:Sodium
keywords: Chronic kidney disease; Hyponatremia; Medical education