Intradialytic Weight Gain Management for Dialysis Patients
The project seeks to improve intradialytic weight gain (IDWG) management in hemodialysis dependent patients by 10% through an education program in 12 weeks. The projects aim is to develop a nurse driven intradialytic weight gain (IDWG) management program that not only educates patients about their target weight (TW), but gives them a better understand of how their actions affect their overall health. This initiative strives to give patients a better understanding of IDWG, target weight and fluid management. The focus of this educational program is not to preach about what the patients should and should not eat or drink, but to educate them about what IDGW means to them as ESRD patients. This may be as simple as giving the educational material in their personal language, such as English, Spanish, Chinese, or Vietnamese. The core team is centered on face-to-face personal time and education about how we can together improve their understanding of IDWG. By improving knowledge of IDWG and their target weights, patients will be better able to self-manage their ESRD resulting in improved outcomes, reduced hospitalizations and fewer complications.
Statement of the Problem
The idea of intradialytic weight gain (IDWG) management is not a new concept and is usually influenced by several factors like psychological, environmental, behavioral, nutritional, and biological factors (Sinclair & Parker, 2008). The issue of IDWG management is not new since patients undergoing hemodialysis are required to follow a complex treatment process that are characterized by fluid and dietary restrictions. Intradialytic weight gain is always used as an indicator for measuring compliance with fluid and dietary restrictions in the complex treatment regime. IDWG management decreases the quality of life for individuals on hemodialysis since it generates co-morbid burdens like chronic fluid overload, hypertension, increased mortality, and congestive heart failure. Despite these significant impacts on people’s health, existing research has only focused on the interventions developed by clinicians rather than how these individuals handle fluid and dietary restrictions in the complex treatment regime. Clinicians tend to focus on developing IDWG interventions and seemingly ignore how people undergoing hemodialysis or ESRD patients understand or comprehend restrictions in the treatment regime. Therefore, this study seeks to ensure patients understand and comprehend the disruptions brought by IDWG management in order to enhance their health outcomes rather than make assumptions about their life experiences when complying with the complex treatment regime.
Much of the focus of current literature in IDWG management for ESRD patients is centered on predictors of non-compliance, interventions to decrease IDWG, and management of intradialytic consequences of IDWG. While this represents a positivist approach to healthcare management and research, it discounts the perspectives or experiences of these patients or people on hemodialysis. Through a perceived needs assessment, interviews and reports from these patients indicates the need for educating them on what IDWG means to them as ESRD patients (see Appendix A). Data analysis that led to this project was based on a rapid assessment of the health outcomes of ESRD patients undergoing IDWG management. This assessment was geared towards identifying suitable measures for enhancing health outcomes for these patients while lessening hospitalizations and complications during IDWG management.
The microsystem data source that indicates the need for this project included a team of health professionals, ESRD patients who receive care from these health professionals, and an information environment that support patients and caregivers’ actions. These various stakeholders provided information regarding IDWG management for ESRD patients relative to improved patient outcomes, which indicated the need for improved understanding of what IDWG really means for these patients. In addition to the microsystem data source, the need for this project was also demonstrate through a needs assessment. The researcher conducted a focus group needs assessment that was centered on group problem analysis. In this case, the group problem analysis was conducted to highlight patients’ perspectives and experiences in IDWG management relative to desired health outcomes.
The needs assessment included an analysis of renal services unit and hemodialysis units with regards to staffing and patient outcomes. The results demonstrated increase in the number of patients reporting dissatisfaction with IDWG management and lack of understanding of what IDWG means to them (see Appendix B). Actually, more than 23% of ESRD patients from these units reported dissatisfaction with and lack of understanding of IDWG management. An audit of the strategies and interventions developed by clinicians towards IDWG management were based on assumptions that patients understand the process and its associated complications. The audit of these units showed that 57% of clinicians recommended IDWG management for ERSD patients without examining patients’ understanding of life experiences and complications. HCAHPS analysis demonstrated that more than 50% of the nursing staff did not communicate well regarding suitable measures to avoid co-morbid burdens brought by the fluid and dietary restrictions in IDWG management.
The projected cost analysis of this project is to save health care facilities over $100,000 annually through reduced hospitalizations and improved outcomes for ESRD patients (see Appendix E). However, the cost of the implementation of this project is approximately $75,000 per year, which entails costs of producing educational materials for patients as well as other components. The net benefit of the project to is estimated to exceed $100,000 within 3 years.
This research will undertake a qualitative study that entails in-depth interviews of patients to elicit their experiences and stories relating to the IDWG management, especially understanding of complications and restrictions. This approach will be suitable for the project because the questioning style in the interviews will be in line with the study’s aims and promote exploration to clarify points. Moreover, the suitability of the approach is on the premise that in-depth interviews help in avoiding probable data collection bias. The implementation of the project will be followed by constant review to examine whether the educational strategies are effective in achieving desired outcomes and determine the need for improvement. The necessary improvements will be implemented once they are identified in order to enhance overall effectiveness. The data results that will be collected to examine the project’s effectiveness will be related to patient outcomes and complications as well as the frequency and extent of hospitalizations. It is expected that the educational measures will generate improved outcomes, fewer complications, and reduced hospitalizations for ESRD patients. The expected results will be checked through comparing pre- and post-project implementation statistics for ERSD patients.
The focus of this study is patient satisfaction because intradialytic weight gain management has been associated with co-morbid burdens that increasingly damage the quality of life for individuals undergoing hemodialysis due to fluid and dietary restrictions. Therefore, enhanced patient outcome is an important concept in IDWG management, which has attracted considerable attention among clinicians and nursing staff. This study seeks to contribute towards enhancing patient outcomes, lessening complications, and reduced hospitalizations through improving patients’ knowledge of IDWG and their target weights. The study demonstrates how education can be used as a suitable measure to fill the gap between IDWG management and improved patients outcomes. In order to accomplish this, the researcher reviewed several articles to support the need for this project.
Since the idea of intradialytic weight gain management is not a new concept, it has been the subject of numerous studies in current literature, especially among ESRD patients. Hecking et al. (2013) define intradialytic weight gain as the difference between an individual’s predialysis weight and his/her weight at the end of previous haemodialytic session (p.80). These researchers state that the link between IDWG and mortality has been analyzed in numerous studies because of poor patient outcomes and further complications. Sinclair & Parker (2008) seemingly support these claims by arguing that IDWG is characterized by co-morbid burdens that increasingly lessen the quality of life for patients undergoing hemodialysis. Most of these burdens are attributed to chronic fluid overload and other complications like congestive heart failure. Consequently, most of the focus on IDWG in current renal literature is centered on interventions to lessen IDWG, controlling the intradialytic consequences, and indicators of non-adherence.
Given the increased complications and relatively poor patient outcomes, measures towards enhancing IDWG management has attracted considerable attention among researchers. Numerous studies exist to support the need for this project exists because of the increased consideration of educational programs as beneficial in IDWG management. Barnett, Li, Pinikahana & Si-Yen (2008) state that an educational program can make a difference with regards to fluid compliance among patients undergoing hemodialysis (p.300). According to these researchers, an educational program is important because patients with end stage renal disease tend to be non-compliant with the complex treatment regime, particularly in relation to compliance to fluid restrictions. These researchers state that the educational program should be driven by nephrology nurses since they have long-term relationships with ESRD patients and are better positioned to offer constant encouragement and education.
In his analysis on the role of education and critical thinking skills in fluid management, Dale (2012) found that education plays an important role in fluid management in IDWG management. The need for an educational program in this process is attributed to the fact that nephrology nurses are required to be proficient, knowledgeable, and competent in fluid management. In concurrence with Barnett, Li, Pinikahana & Si-Yen (2008), Dale (2012) suggests that the educational program for fluid management in IDWG management should be driven by competent, knowledgeable, and proficient nephrology nurses. Critical thinking plays a crucial role in the educational program since it encourages nurses to utilize intellectual reasoning to make relevant and suitable clinical decisions (Dale, 2012, p.511).
Lingerfelt & Thornton (2011) supports the case for educating ESRD patients undergoing hemodialysis by arguing that patient education is vital to people with this condition to encourage self-management practices (p.483). They support the need for patient education on the premise that it enables patients to understand and comprehend co-morbidities in IDWG management that enhance mortality rates. Lingerfelt & Thornton (2011) further contend that patient knowledge and understanding of hemodialysis and ESRD is important towards better self-management and enhanced patient outcomes. The improved patient outcomes are realized through addressing modifiable risk factors among these patients such as treatment, diet, and medication compliance. These researchers’ argument that patient education is crucial towards effective self-management and better outcomes is supported by the fact that enhanced patient knowledge has been associated with positive effects on self-management activities and behaviors, which result in better patient outcomes.
Kugler, Maeding & Russell (2010) supports Lingerfelt & Thornton (2011) through conducting an international comparison of non-compliance in patients suffering from chronic hemodialysis. In their study, Kugler, Maeding & Russell (2010) conclude that patients’ nutritional habits, particularly fluid and dietary restrictions, are highly linked to illness-specific knowledge and successive delivery of patient education. This implies that poor nutritional habits among patients with chronic hemodialysis are attributed to their poor level of knowledge regarding the disease and lack of provision of adequate patient education. As a result, these researchers seemingly support the significance of patient education in effective self-management and improved outcomes for ESRD patients as suggested by Lingerfelt & Thornton (2012).
Baraz, Parvardeh, Mohammadi & Broumand (2009) conducted a study on dietary and fluid compliance with a view of determining the impact of an educational intervention for ESRD patient or people undergoing hemodialysis. These researchers concur with Lingerfelt & Thornton (2012) by determining that educational intervention in such patients is relatively effective in enhancing their adherence with fluid and dietary restrictions. They postulate that enhancing patients’ knowledge should a crucial component of treatment because of its role in enhancing an individual’s compliance with the complex treatment and therapeutic regime.
Alikari et al. (2015) also concurs with Lingerfelt & Thornton (2012) claims that patient knowledge regarding ESRD and hemodialysis has proven to generate positive impacts on patient outcomes (p.515). In their study on the impact of nursing counseling on enhancing knowledge, treatment compliance, and patient outcomes, Alikari et al. (2015) state that self-efficacy and involvement in clinical decision making are positively linked to high extent of knowledge regarding the disease. They found that compliance with treatment, especially in relation to dietary and fluid restrictions, for ESRD patients undergoing hemodialysis is usually dependent on knowledge about the disease and these restrictions.
The identification of this literature that demonstrates the need for this project entailed the use of a PICO search statement. Generally, PICO is used in evidence-based practice in nursing to help as a process for formulating research questions. The taxonomy is used to develop questions in the nursing field that are divided into four major components i.e. patient or population, intervention or indicator, control or comparator, and outcome. The PICO search statement that was used for identifying suitable literature for this study is, “The significance of a nurse-driven IDWG management program for ESRD patients undergoing hemodialysis in order to generate enhanced outcomes, fewer complications, and decreased hospitalizations.” The population is ESRD patients undergoing hemodialysis whereas the intervention is an educational program in IDWG management. The control is increased self-management of the disease and outcome is improved patient outcomes, reduced complications, and decreased hospitalizations. Each piece of the literature review generated through the PICO search statement supports by project and problem statement by demonstrating the complications in IDWG management and the significance of an educational intervention to improve patient outcomes.
The project is expected to improve ESRD patients’ understanding of IDWG through enhanced knowledge of the disease and target weights as well as improved self-management practices that generate improved outcomes, fewer complications, and reduced hospitalizations (Appendix C). The conclusions that are likely to emerge from this study include the proposal that interventions to improve IDWG management should address motivational issues and enhance patient knowledge for better patient outcomes (Smith et al., 2011, p.334). The other conclusion that is likely to emerge from the study is that educational interventions that empower patients generate positive impacts in the management of chronic diseases (Kotsirilos, Vitetta & Sali, 2011, p.800).
Based on the expected results of this project, the study will generate significant contributions to the current understanding of IDWG management. As previously described, current literature and practices largely focus on the development of interventions by clinicians to lessen IDWG for ESRD patients undergoing hemodialysis with little regard on patients’ experiences. This study generates significant contribution by postulating that educational interventions are increasingly likely to be effective in lessening IDWG than developing new interventions (see Appendix D). The study also indicates that psychological or motivational issues and patients’ knowledge is crucial towards effective IDWG management with regards to positive patient outcomes and fewer complications.
Alikari, V., Matziou, V., Tsironi, M., Theofilou, P. & Zyga, S. (2015, May-August). The Effect of Nursing Counseling on Improving Knowledge, Adherence to Treatment and Quality of Life of Patients Undergoing Hemodialysis. International Journal of Caring Sciences, 8(2), 514-518.
Baraz, S., Paravardeh, S., Mohammadi, E., & Broumand, B. (2009, July 10). Dietary and Fluid Compliance: An Education Intervention for Patients having Haemodialysis. Journal of Advanced Nursing, 66(1), 60-68.
Barnett, T., Li, Y.T., Pinikahana, J. & Si-Yen, T. (2008, February). Fluid Compliance among Patients having Haemodialysis: Can an Educational Programme Make a Difference? Journal of Advanced Nursing, 61(3).
Dale, W. (2012, Nov-Dec). Education in Fluid Management and Encouraging Critical Thinking Skills. Nephrology Nursing Journal, 39(6), 510-512.
Hecking et al. (2013, July 6). Significance of Interdialytic Weight Gain vs. Chronic Volume Overload: Consensus Opinion. American Journal of Nephrology, 38, 78-90.
Kotsirilos, V., Vitetta, L. & Sali, A. (2011). A guide to evidence-based integrative and complementary medicine. Chatswood, NSW: Elsevier Australia.
Kugler, C., Maeding, I. & Russell, C.L. (2011). Non-adherence in Patients on Chronic Hemodialysis: An International Comparison Study. Journal of Nephrology, 24(3), 366-375.
Lingerfelt, K. & Thornton, K. (2011). An Educational Project for Patients on Hemodialysis to Promote Self-Management Behaviors of End Stage Renal Disease. Nephrology Nursing Journal, 38(6), 483-489.
Sinclair, P. & Parker, V. (2008). Pictures and Perspectives — A Unique Reflection on Interdialytic Weight Gain. Nephrology Nursing Journal, 36(6), 589-596.
Smith et al. (2010, September). Patient Perspectives on Fluid Management in Chronic Hemodialysis. Journal of Renal Nutrition, 20(5), 334-341.
Appendix A: Process Mapping (Flow Chart)
Patient with ERSD
Referral to Dialysis Unit
Renal Therapy Placement
Quality of Life
Fluid and Diet Restrictions
Hospitalization and Complications
Appendix B: Root Cause Analysis (Fishbone Diagram)
Non-adherence with the Complex Treatment Regime
Unaware of Patient experiences
Lack of Patient Education
Appendix C: SWOT Analysis
Supportive Patient Care
Better IDWG Management
Better IDWG Understanding
Fluid and Diet Restrictions
Enhanced Patient Education
Provision of more Educational Materials
Lack of coordination
Lack of Follow-up
Appendix D: Stakeholder Analysis
– Will need to make significant investments in educational materials and resources.
– High priority: educational intervention in IDWG management for ESRD patients has been identified as a crucial factor in enhanced patient outcomes.
Nursing Staff or Clinicians
– Will need to incorporate patient education in the various initiatives towards lessening excessive IDWG for ESRD patients undergoing hemodialysis.
– Will need to ensure current practices are not based on assumptions or disregard of patients’ experiences in IDWG management, especially diet and fluid restrictions.
– Nursing buy-in is vital in ensuring effective patient education and improved quality of care that generates better patient outcomes, fewer complications, and reduced hospitalizations.
– Very influential and significant in the direction of renal care in dialysis centers and units.
– Very interested in the establishment of effective interventions and measures to enhance renal care and patients’ quality of life.
– Need to identify and utilize suitable measures for IDWG management, particularly fluid and diet restrictions.
– Need better understanding of what IDWG really means to them and their target weights.
– Need to better self-manage their ESRD conditions.
– Will likely be impacted by educational interventions.
– Their satisfaction is likely to improve because of fewer complications, better outcomes, and reduced hospitalizations.
Appendix E: Projected Cost Analysis
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