Nutrition Optimization in Early Dialysis

Protein-energy wasting (PEW) syndrome is a common condition among patients suffering from end-stage renal disease (ESRD) receiving intermittent hemodialysis (IHD). Hospital nutrition barriers such as delayed meals and iatrogenic fasting can negatively affect patients' experiences and contribute to long-standing nutritional deficits in at-risk patients. This project aimed to improve nutrition provision to inpatients with early IHD appointments by 50% (relative increase) without increasing IHD start time delays.

The Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) methodology was used to guide the overall framework for process improvement, while specific improvements were implemented using Plan-Do-Study-Act (PDSA) cycles. Baseline data were analyzed for early morning appointments (5:00 a.m.-6:00 a.m.), and fishbone and Pareto charts were used to identify key barriers to nutrition availability. PDSA cycles were implemented to improve nutrition provision. Chi-square tests were conducted to assess significant changes in the percentage of patients reporting improved nutrition provision and reduced delays in dialysis start times.

Baseline data showed that 38.6% of early IHD patients with diet orders at one tertiary care center received breakfast prior to their appointment. Stakeholder analysis and Pareto charts revealed that the mismatch between IHD start times and early meal tray delivery was a root cause. The first PDSA cycle adjusted nursing workflows, substituting early meals with bento snack boxes, achieving 54.2% nutrition provision. Following patient feedback, protein shakes were added, increasing provision to 93.8%. IHD start time delays decreased from 24.6% at baseline to an average of 10.2%, with these improvements sustained beyond 30 days postintervention.

The use of quality improvement methodology effectively improved nutrition delivery for high-risk patients and was associated with reduced hemodialysis start time delays and enhanced organizational efficiency. This project addressed a specific concern relating to patients receiving dialysis due to baseline rates of undernutrition and barriers to providing nourishment in the hospital. Future studies should focus on further analysis of patients on dialysis and expand to include other hospitalized subpopulations at risk for undernutrition, to optimize and generalize these interventions more broadly.