10 Strategic Points Document for a Quality Improvement Project Paper

10 Strategic Points Document for a Quality Improvement Project Paper

The 10 Strategic Points
Title of Project The impact of Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload on weights of renal disease adults in hemodialysis facility.
Background

Theoretical Foundation

Literature Synthesis

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Practice Change Recommendation

 

        i.            Background

·         End-stage renal disease adults require kidney transplants or hemodialysis to help them stay alive.

·         The primary role of maintenance hemodialysis (HD) is the extracellular fluid volume (ECV) balance, which makes sodium balance possible between interdialytic sodium intake and sodium removal during HD sessions.  The problem addressed in the project is the relationship between adherence to fluid and diet restrictions and interdialytic weight gain among ESRD patients undergoing hemodialysis. Previous studies have shown that a positive dialysate-to-plasma sodium gradient is associated with increased thirst and interdialytic weight gain among ESRD patients (Jalalzadeh et al., 2021). However, there is a need for further studies on the effect of patient education on fluid and diet restrictions on patient adherence to the set restrictions.

o   Significance of the problem: interdialytic weight gain can lead to a number of adverse health outcomes for ESRD patients. Fluid overload can increase the workload on the heart and lead to heart failure, while weight gain can exacerbate other underlying health conditions such as hypertension and diabetes (Weiner et al., 2017). Additionally, maintaining an appropriate weight through adherence to fluid and diet restrictions can improve the overall quality of life for ESRD patients.

o   Moreover, the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines on nutrition recommendations for each stage of chronic kidney disease which is significant to be followed, as adherence to these guidelines could potentially have a significant impact on the weight and overall health outcomes of ESRD patients undergoing hemodialysis (Sakai et al., 2017)

ii.            Theoretical foundations:

·         Henderson’s Nursing Need Theory: Henderson’s Nursing Need theory emphasizes the importance of providing nursing care that addresses the physical, psychological, and social needs of patients (Masters, 2014). The concepts of addressing the physical, psychological, and social needs align with the problem of interdialytic weight gain among ESRD patients in that it highlights the importance of addressing the physical needs of patients through appropriate fluid and diet management.

·         Cognitive Dissonance theory: Cognitive Dissonance theory suggests that individuals may experience psychological discomfort or dissonance when confronted with conflicting attitudes or behaviors (Masters, 2014). This theory aligns with the problem of interdialytic weight gain among ESRD patients in that it helps to understand how patients may struggle with the restrictions imposed by fluid and diet management and how they might change their attitudes or behaviors to resolve the discomfort.

·         The Health Belief Model: The Health Belief Model posits that individuals’ perceived susceptibility to a health problem, perceived seriousness of the problem, perceived benefits of taking action, perceived barriers to taking action, and cues to action all play a role in determining whether an individual will engage in health-promoting behaviors (Masters, 2014). This theory aligns with the problem of interdialytic weight gain among ESRD patients in that it helps to understand how patient’s perception of the problem and their perceived benefit of taking action influence their adherence to fluid and diet restrictions.

 

Explanation: These theories were chosen as the theoretical foundations for the project because they provide a framework for understanding how patients may struggle with the restrictions imposed by fluid and diet management and how they might change their attitudes or behaviors to resolve the discomfort, and how patient’s perception of the problem and their perceived benefit of taking action influence their adherence to fluid and diet restrictions. By understanding these underlying psychological and social factors, the project aims to develop effective strategies for improving adherence to fluid and diet restrictions among ESRD patients, which could ultimately lead to better weight outcomes and improved overall health for these patients.

    iii.            Review of literature topics

·         About End Stage Renal Disease (ESRD) and chronic kidney disease (CKD)

·         What is diet and fluid restriction

·         Strategies for diet and fluid management

·         What is intradialytic weight

·         Best practices for engaging patients within fluid and diet restrictions

·         Diet and fluid restriction reduces inter-dialytic weight gain in ESRD patients

 

Annotated Bibliography

Jalalzadeh, M., Mousavinasab, S., Villavicencio, C., Aameish, M., Chaudhari, S., & Baumstein, D. (2021). Consequences of Interdialytic Weight Gain Among Hemodialysis Patients. Cureus, 13(5), e15013. https://doi.org/10.7759/cureus.15013

 

Masters, K. (2014). Nursing theories: A framework for professional practice (2nd ed.). Jones & Bartlett. https://books.google.at/books?id=sd0-BAAAQBAJ

 

Perez, L. M., Fang, H. Y., Ashrafi, S. A., Burrows, B. T., King, A. C., Larsen, R. J., … & Wilund, K. R. (2021). A pilot study to reduce interdialytic weight gain by providing low‐sodium, home‐delivered meals to hemodialysis patients. Hemodialysis International25(2), 265–274. https://doi.org/10.1111/hdi.12902

 

Ramaswamy, K., Brahmbhatt, Y., Xia, J., Song, Y., & Zhang, J. (2020). Individualized dialysate sodium prescriptions using sodium gradients for high‐risk hemodialysis patients lowered interdialytic weight gain and achieved target weights. Hemodialysis International24(3), 406–413. https://doi.org/10.1111/hdi.12830

 

Sakai, A., Hamada, H., Hara, K., Mori, K., Uchida, T., Mizuguchi, T., Minaguchi, J., Shima, K., Kawashima, S., Hamada, Y., & Nikawa, T. (2017). Nutritional counseling regulates interdialytic weight gain and blood pressure in outpatients receiving maintenance hemodialysis. The journal of medical investigation: JMI64(1.2), 129–135. https://doi.org/10.2152/jmi.64.129

 

Weiner, D. E., Brunelli, S. M., Hunt, A., Schiller, B., Glassock, R., Maddux, F. W., … & Nissenson, A. (2017). We are improving clinical outcomes among hemodialysis patients: a proposal for a “volume first” approach from the chief medical officers of US dialysis providers. American journal of kidney diseases64(5), 685-695. https://doi.org/10.1053/j.ajkd.2014.07.003

 

Wong, M. M., McCullough, K. P., Bieber, B. A., Bommer, J., Hecking, M., Levin, N. W., McClellan, W. M., Pisoni, R. L., Saran, R., Tentori, F., Tomo, T., Port, F. K., & Robinson, B. M. (2017). Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes in the International Dialysis Outcomes and Practice Patterns Study (DOPPS). American journal of kidney diseases: the official journal of the National Kidney Foundation69(3), 367–379. https://doi.org/10.1053/j.ajkd.2016.08.030

 

Sufficient fluid volume management in hemodialytic persons is essential for patient outcomes and experience (Iseki, 2022). Volume overload may result in breathlessness and peripheral edema (Dasgupta et al., 2019). The long-term effects include left ventricular hypertrophy, hypertension, and heart failure, which are associated with higher mortality rates. Current practices, including low dialysate sodium concentration (DNa), have not been effective: excessive fluid removal may result in abdominal pain, dizziness, cramps, and vomiting (Dasgupta et al., 2019). According to the KDOQI guidelines, sodium intake is limited to less than 2.3g daily (100mmol daily) sodium or less than 5.8g salt to improve volume control and reduce blood pressure in Chronic Kidney Disease (CKD) 3 to 5, post-transplantation, or CKD5D patients (Iseki, 2022).

Problem Statement End-stage renal disease adults in hemodialysis facilities have experienced weight-related problems. It has yet to be determined if implementing the fluid in the Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload impact interdialytic weight restriction would impact the amounts of fluid gained among outpatients with End-Stage Renal Disease (ESRD)

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PICOT to Evidence-Based Question         i.            In end-stage renal disease adults in a hemodialysis facility, does the Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload impact interdialytic weight gain versus current practice over 12 weeks?

 

ii.            Understanding the relationships and impacts of Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload on the weights of renal disease adults in hemodialysis facilities in Volusia County, state of Florida, is essential.

Sample

Setting

Location

Inclusion and Exclusion Criteria

The patients must have been diagnosed with End Stage Renal Disease (ESRD) and undergoing sustained hemodialysis for more than 90 days. The patients will be derived from health facilities within Volusia County, Florida. The population is outpatient with a diagnosis of end-stage renal disease number based on the G*power analysis sample size calculator. Explain potential bias and mitigation of sample size:

i.          Dialysis Facilities

ii.          Rural city in Florida

iii.          Inclusion Criteria

·            Has been diagnosed with End-stage renal disease

·            Aged 18 years and above

·            Is a current patient at DaVita Port Orange Dialysis

·            Sober state of mind and capable of giving consent legally

 

v.      Who cannot participate

·         Is below 18 years old

·         Is not a current patient at DaVita Port Orange Dialysis.

·         Has not been diagnosed with End stage renal disease

Define Variables         i.            Independent variable: Data on the gender, level of education, occupation, and duration of ESRD will be collected using a standard survey questionnaire for the patient demographics.

 

ii.            Dependent variable: Level of engagement with fluid and dietary restriction knowledge. Data will be collected using the modified end-stage renal disease adherence questionnaire in similar studies. The questionnaire includes items on diets, fluids, and adherence behaviors.

  1. Dependent variable: Inter-dialytic weight gain. The Hemodialysis/Inter-dialytic weight flow sheet will be used to collect data. The flow sheet captures data such as treatment time, dialysis solution, pre-dialytic weight, post-dialytic weight, and laboratory results
Project Design This project will use a quality improvement approach.

i.            According to the Centers for Medicare & Medicaid Services (CMS), quality is defined by the National Academy of Medicine as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality improvement is the framework used to improve care systematically. Quality improvement seeks to standardize processes and structures to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations (CMS.gov).

ii.            The federal government defines research as a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge (HHS.gov). Research yields valid results through the strict implementation of a fixed protocol. The focus of research is on long-term gains in learning.

 

iii.            There are many similarities and differences between research and QI:

 

·         Similarities

o   Both involve a systematic investigation designed to achieve reliable and valid results. Both involve the analysis of data.

o   Both may involve the implementation of a new intervention.

o   Both may result in a presentation or publication.

 

·         Differences

o   QI projects are often flexible and incremental in design, employing strategies such as a plan-do-study-act cycle.

o   QI uses data analysis to determine whether the workforce follows best practices and professional guidelines.

o   It implements a new practice or process to improve (for example) workflow, patient safety, staff expertise, cost-effectiveness, etc.

o   QI interventions often have been proven to be successful elsewhere and are widely accepted in the profession/discipline. It evaluates the best strategies to implement these interventions locally.

o   QI projects can help characterize the population to serve their needs better or improve their care. Its projects aim to directly benefit existing patients by implementing immediate local improvements.

o   QI does not increase patient risk beyond the risks involved in the care they are already receiving.

o   QI tools apply primarily to the unique characteristics of our local setting.

o   The results of QI projects typically are evaluated by an internal committee or executives who decide whether to adopt the new practice permanently.

Purpose Statement The aim or purpose of this study is to determine if the implementation of the Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload on diet and the fluid restriction would impact fluid gain between dialysis within the first eight weeks of hemodialysis among outpatients with End-Stage Renal Disease (ESRD) in a Hemodialysis facility located in rural Florida.
Data Collection Approach         i.            A Modified End Stage Renal Disease adherence questionnaire (ESRD-AQ) and a Hemodialysis/Inter-dialytic weight Flow Sheet (HFS) are the primary tools for this study.

 

ii.            Permission will be needed to allow the patient from hemodialysis facilities to participate in the study. Approximately 60 participants will be asked to take part in the survey. The data will be collected, as illustrated, through questionnaires and weight sheets. They will then be stored in electric format. Participants will have informed consent, and their privacy will be maintained.

Data Analysis Approach         i.            A Modified End Stage Renal Disease adherence questionnaire (ESRD-AQ) and a Hemodialysis/Inter-dialytic weight Flow Sheet (HFS) are the primary tools for this study.

ii.            Descriptive statistics on SPSS will be used to analyze the data. Patient demographics will be summarized into standard deviations, means, medians, percentages, and interquartile ranges for the categorical and continuous data. Chi-squares and three-way contingency tables will be used to test associations between the identified variables, helping to categorize the patient adherence to fluid restrictions, medications, dietary recommendations, and hemodialysis schedules into aggregated scores.

 

iii.            Notably, T-tests will be employed to help determine the relationships concerning weight pre-dialysis and post-dialysis and compare the weight loss across the sample based on age. A binomial logistic regression analysis will then be conducted to identify the correlation between diet and fluid restriction education, patient adherence level, and inter-dialytic weight gain.

References Jalalzadeh, M., Mousavinasab, S., Villavicencio, C., Aameish, M., Chaudhari, S., & Baumstein, D. (2021). Consequences of Interdialytic Weight Gain Among Hemodialysis Patients. Cureus, 13(5), e15013. https://doi.org/10.7759/cureus.15013

Landrum, B., & Garza, G. (2015). Mending fences: Defining the domains and approaches of quantitative and qualitative research. Qualitative Psychology, 2(2), 199–209. https://doi.org/10.1037/qup0000030

Perez, L. M., Fang, H. Y., Ashrafi, S. A., Burrows, B. T., King, A. C., Larsen, R. J., … & Wilund, K. R. (2021). A pilot study to reduce interdialytic weight gain by providing low‐sodium, home‐delivered meals to hemodialysis patients. Hemodialysis International25(2), 265–274. https://doi.org/10.1111/hdi.12902

 

Ramaswamy, K., Brahmbhatt, Y., Xia, J., Song, Y., & Zhang, J. (2020). Individualized dialysate sodium prescriptions using sodium gradients for high‐risk hemodialysis patients lowered interdialytic weight gain and achieved target weights. Hemodialysis International24(3), 406–413. https://doi.org/10.1111/hdi.12830

 

Sakai, A., Hamada, H., Hara, K., Mori, K., Uchida, T., Mizuguchi, T., Minaguchi, J., Shima, K., Kawashima, S., Hamada, Y., & Nikawa, T. (2017). Nutritional counseling regulates interdialytic weight gain and blood pressure in outpatients receiving maintenance hemodialysis. The journal of medical investigation: JMI64(1.2), 129–135. https://doi.org/10.2152/jmi.64.129

 

Weiner, D. E., Brunelli, S. M., Hunt, A., Schiller, B., Glassock, R., Maddux, F. W., … & Nissenson, A. (2017). We are improving clinical outcomes among hemodialysis patients: a proposal for a “volume first” approach from the chief medical officers of US dialysis providers. American journal of kidney diseases64(5), 685-695. https://doi.org/10.1053/j.ajkd.2014.07.003

 

Wong, M. M., McCullough, K. P., Bieber, B. A., Bommer, J., Hecking, M., Levin, N. W., McClellan, W. M., Pisoni, R. L., Saran, R., Tentori, F., Tomo, T., Port, F. K., & Robinson, B. M. (2017). Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes in the International Dialysis Outcomes and Practice Patterns Study (DOPPS). American journal of kidney diseases: the official journal of the National Kidney Foundation69(3), 367–379. https://doi.org/10.1053/j.ajkd.2016.08.030

 

What is Human Subjects Research? | HHS.gov. https://www.hhs.gov/ohrp/education-and-outreach/online-education/human-research-protection-training/lesson-2-what-is-human-subjects-research/index.html

 

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10 Strategic Points Document for a Quality Improvement Project
The 10 Strategic Points
Title of Project The impact of Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload on weights of renal disease adults in hemodialysis facility.
Background
Theoretical Foundation
Literature Synthesis
Practice Change Recommendation
i. Background
• End-stage renal disease adults require kidney transplants or hemodialysis to help them stay alive.
• The primary role of maintenance hemodialysis (HD) is the extracellular fluid volume (ECV) balance, which makes sodium balance possible between interdialytic sodium intake and sodium removal during HD sessions. Studies show that a positive dialysate-to-plasma sodium gradient is associated with increased thirst and interdialytic weight gain (citation; citation).
o Previous studies point to a relationship between fluid and diet restrictions adherence and the level of inter-dialytic weight gain among ESRD patients (citation; citation; citation).
o Need for further studies on the effect of patient education on fluid and diet restriction on patient adherence to the set restrictions
o Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines on nutrition recommendations for each stage of chronic kidney disease

ii. Theoretical foundation
• Henderson’s Nursing Need Theory
• Cognitive Dissonance theory
• The Health Belief Model

iii. Review of literature topics
• About End Stage Renal Disease (ESRD) and chronic kidney disease (CKD)
• What is diet and fluid restriction
• Strategies for diet and fluid management
• What is intradialytic weight
• Best practices for engaging patients within fluid and diet restrictions
• Diet and fluid restriction reduces inter-dialytic weight gain in ESRD patients

Annotated Bibliography
Jalalzadeh, M., Mousavinasab, S., Villavicencio, C., Aameish, M., Chaudhari, S., & Baumstein, D. (2021). Consequences of Interdialytic Weight Gain Among Hemodialysis Patients. Cureus, 13(5), e15013. https://doi.org/10.7759/cureus.15013

Perez, L. M., Fang, H. Y., Ashrafi, S. A., Burrows, B. T., King, A. C., Larsen, R. J., … & Wilund, K. R. (2021). A pilot study to reduce interdialytic weight gain by providing low‐sodium, home‐delivered meals to hemodialysis patients. Hemodialysis International, 25(2), 265–274. https://doi.org/10.1111/hdi.12902

Ramaswamy, K., Brahmbhatt, Y., Xia, J., Song, Y., & Zhang, J. (2020). Individualized dialysate sodium prescriptions using sodium gradients for high‐risk hemodialysis patients lowered interdialytic weight gain and achieved target weights. Hemodialysis International, 24(3), 406–413. https://doi.org/10.1111/hdi.12830

Sakai, A., Hamada, H., Hara, K., Mori, K., Uchida, T., Mizuguchi, T., Minaguchi, J., Shima, K., Kawashima, S., Hamada, Y., & Nikawa, T. (2017). Nutritional counseling regulates interdialytic weight gain and blood pressure in outpatients receiving maintenance hemodialysis. The journal of medical investigation: JMI, 64(1.2), 129–135. https://doi.org/10.2152/jmi.64.129

Weiner, D. E., Brunelli, S. M., Hunt, A., Schiller, B., Glassock, R., Maddux, F. W., … & Nissenson, A. (2017). We are improving clinical outcomes among hemodialysis patients: a proposal for a “volume first” approach from the chief medical officers of US dialysis providers. American journal of kidney diseases, 64(5), 685-695. https://doi.org/10.1053/j.ajkd.2014.07.003

Wong, M. M., McCullough, K. P., Bieber, B. A., Bommer, J., Hecking, M., Levin, N. W., McClellan, W. M., Pisoni, R. L., Saran, R., Tentori, F., Tomo, T., Port, F. K., & Robinson, B. M. (2017). Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes in the International Dialysis Outcomes and Practice Patterns Study (DOPPS). American journal of kidney diseases: the official journal of the National Kidney Foundation, 69(3), 367–379. https://doi.org/10.1053/j.ajkd.2016.08.030

Sufficient fluid volume management in hemodialytic persons is essential for patient outcomes and experience (Iseki, 2022). Volume overload may result in breathlessness and peripheral edema (Dasgupta et al., 2019). The long-term effects include left ventricular hypertrophy, hypertension, and heart failure, which are associated with higher mortality rates. Current practices, including low dialysate sodium concentration (DNa), have not been effective: excessive fluid removal may result in abdominal pain, dizziness, cramps, and vomiting (Dasgupta et al., 2019). According to the KDOQI guidelines, sodium intake is limited to less than 2.3g daily (100mmol daily) sodium or less than 5.8g salt to improve volume control and reduce blood pressure in Chronic Kidney Disease (CKD) 3 to 5, post-transplantation, or CKD5D patients (Iseki, 2022).
Problem Statement End-stage renal disease adults in hemodialysis facilities have experienced weight-related problems. It has yet to be determined if implementing the fluid in the Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload impact interdialytic weight restriction would impact the amounts of fluid gained among outpatients with End-Stage Renal Disease (ESRD)
PICOT to Evidence-Based Question i. In end-stage renal disease adults in a hemodialysis facility, does the Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload impact interdialytic weight gain versus current practice over 12 weeks?

ORDER A PLAGIARISM-FREE PAPER HERE

ii. Understanding the relationships and impacts of Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload on the weights of renal disease adults in hemodialysis facilities in Volusia County, state of Florida, is essential.
Sample
Setting
Location
Inclusion and Exclusion Criteria The patients must have been diagnosed with End Stage Renal Disease (ESRD) and undergoing sustained hemodialysis for more than 90 days. The patients will be derived from health facilities within Volusia County, Florida. The population is outpatient with a diagnosis of end-stage renal disease number based on the G*power analysis sample size calculator. Explain potential bias and mitigation of sample size:
i. Dialysis Facilities
ii. Rural city in Florida
iii. Inclusion Criteria
• Has been diagnosed with End-stage renal disease
• Aged 18 years and above
• Is a current patient at DaVita Port Orange Dialysis
• Sober state of mind and capable of giving consent legally

v. Who cannot participate
• Is below 18 years old
• Is not a current patient at DaVita Port Orange Dialysis.
• Has not been diagnosed with End stage renal disease
Define Variables i. Independent variable: Data on the gender, level of education, occupation, and duration of ESRD will be collected using a standard survey questionnaire for the patient demographics.

ii. Dependent variable: Level of engagement with fluid and dietary restriction knowledge. Data will be collected using the modified end-stage renal disease adherence questionnaire in similar studies. The questionnaire includes items on diets, fluids, and adherence behaviors.
iii. Dependent variable: Inter-dialytic weight gain. The Hemodialysis/Inter-dialytic weight flow sheet will be used to collect data. The flow sheet captures data such as treatment time, dialysis solution, pre-dialytic weight, post-dialytic weight, and laboratory results
Project Design This project will use a quality improvement approach.
i. According to the Centers for Medicare & Medicaid Services (CMS), quality is defined by the National Academy of Medicine as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality improvement is the framework used to improve care systematically. Quality improvement seeks to standardize processes and structures to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations (CMS.gov).
ii. The federal government defines research as a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge (HHS.gov). Research yields valid results through the strict implementation of a fixed protocol. The focus of research is on long-term gains in learning.

iii. There are many similarities and differences between research and QI:

• Similarities
o Both involve a systematic investigation designed to achieve reliable and valid results. Both involve the analysis of data.
o Both may involve the implementation of a new intervention.
o Both may result in a presentation or publication.

• Differences
o QI projects are often flexible and incremental in design, employing strategies such as a plan-do-study-act cycle.
o QI uses data analysis to determine whether the workforce follows best practices and professional guidelines.
o It implements a new practice or process to improve (for example) workflow, patient safety, staff expertise, cost-effectiveness, etc.
o QI interventions often have been proven to be successful elsewhere and are widely accepted in the profession/discipline. It evaluates the best strategies to implement these interventions locally.
o QI projects can help characterize the population to serve their needs better or improve their care. Its projects aim to directly benefit existing patients by implementing immediate local improvements.
o QI does not increase patient risk beyond the risks involved in the care they are already receiving.
o QI tools apply primarily to the unique characteristics of our local setting.
o The results of QI projects typically are evaluated by an internal committee or executives who decide whether to adopt the new practice permanently.
Purpose Statement The aim or purpose of this study is to determine if the implementation of the Kidney Disease Outcome Quality Initiative Nutrition Guideline for intradialytic sodium and fluid overload on diet and the fluid restriction would impact fluid gain between dialysis within the first eight weeks of hemodialysis among outpatients with End-Stage Renal Disease (ESRD) in a Hemodialysis facility located in rural Florida.
Data Collection Approach i. A Modified End Stage Renal Disease adherence questionnaire (ESRD-AQ) and a Hemodialysis/Inter-dialytic weight Flow Sheet (HFS) are the primary tools for this study.

ii. Permission will be needed to allow the patient from hemodialysis facilities to participate in the study. Approximately 60 participants will be asked to take part in the survey. The data will be collected, as illustrated, through questionnaires and weight sheets. They will then be stored in electric format. Participants will have informed consent, and their privacy will be maintained.
Data Analysis Approach i. A Modified End Stage Renal Disease adherence questionnaire (ESRD-AQ) and a Hemodialysis/Inter-dialytic weight Flow Sheet (HFS) are the primary tools for this study.
ii. Descriptive statistics on SPSS will be used to analyze the data. Patient demographics will be summarized into standard deviations, means, medians, percentages, and interquartile ranges for the categorical and continuous data. Chi-squares and three-way contingency tables will be used to test associations between the identified variables, helping to categorize the patient adherence to fluid restrictions, medications, dietary recommendations, and hemodialysis schedules into aggregated scores.

iii. Notably, T-tests will be employed to help determine the relationships concerning weight pre-dialysis and post-dialysis and compare the weight loss across the sample based on age. A binomial logistic regression analysis will then be conducted to identify the correlation between diet and fluid restriction education, patient adherence level, and inter-dialytic weight gain.
References Jalalzadeh, M., Mousavinasab, S., Villavicencio, C., Aameish, M., Chaudhari, S., & Baumstein, D. (2021). Consequences of Interdialytic Weight Gain Among Hemodialysis Patients. Cureus, 13(5), e15013. https://doi.org/10.7759/cureus.15013
Landrum, B., & Garza, G. (2015). Mending fences: Defining the domains and approaches of quantitative and qualitative research. Qualitative Psychology, 2(2), 199–209. https://doi.org/10.1037/qup0000030
Perez, L. M., Fang, H. Y., Ashrafi, S. A., Burrows, B. T., King, A. C., Larsen, R. J., … & Wilund, K. R. (2021). A pilot study to reduce interdialytic weight gain by providing low‐sodium, home‐delivered meals to hemodialysis patients. Hemodialysis International, 25(2), 265–274. https://doi.org/10.1111/hdi.12902

Ramaswamy, K., Brahmbhatt, Y., Xia, J., Song, Y., & Zhang, J. (2020). Individualized dialysate sodium prescriptions using sodium gradients for high‐risk hemodialysis patients lowered interdialytic weight gain and achieved target weights. Hemodialysis International, 24(3), 406–413. https://doi.org/10.1111/hdi.12830

Sakai, A., Hamada, H., Hara, K., Mori, K., Uchida, T., Mizuguchi, T., Minaguchi, J., Shima, K., Kawashima, S., Hamada, Y., & Nikawa, T. (2017). Nutritional counseling regulates interdialytic weight gain and blood pressure in outpatients receiving maintenance hemodialysis. The journal of medical investigation: JMI, 64(1.2), 129–135. https://doi.org/10.2152/jmi.64.129

Weiner, D. E., Brunelli, S. M., Hunt, A., Schiller, B., Glassock, R., Maddux, F. W., … & Nissenson, A. (2017). We are improving clinical outcomes among hemodialysis patients: a proposal for a “volume first” approach from the chief medical officers of US dialysis providers. American journal of kidney diseases, 64(5), 685-695. https://doi.org/10.1053/j.ajkd.2014.07.003

Wong, M. M., McCullough, K. P., Bieber, B. A., Bommer, J., Hecking, M., Levin, N. W., McClellan, W. M., Pisoni, R. L., Saran, R., Tentori, F., Tomo, T., Port, F. K., & Robinson, B. M. (2017). Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes in the International Dialysis Outcomes and Practice Patterns Study (DOPPS). American journal of kidney diseases: the official journal of the National Kidney Foundation, 69(3), 367–379. https://doi.org/10.1053/j.ajkd.2016.08.030

What is Human Subjects Research? | HHS.gov. https://www.hhs.gov/ohrp/education-and-outreach/online-education/human-research-protection-training/lesson-2-what-is-human-subjects-research/index.html

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