DaVita® Medical Insights

Recovery Nutrition for Preventing Hospital Readmissions for Dialysis Patients

Approximately 35 percent of hospitalized dialysis patients are readmitted to the hospital within 30 days of discharge—which is higher than the estimated 17 to 18 percent readmission rate for all hospitalized patients. As the importance of reducing hospitalizations has been increasingly recognized, readmission rates have begun to tie to financial incentives and quality of care. In 2018, dialysis centers are required to report the Standard Hospitalization Ratio (SHR) and Standard Readmission Ratio (SRR) to The Centers for Medicare & Medicaid Services (CMS) for inclusion in both the CMS Quality Incentive Plan (QIP) and CMS Five-Star Quality Ratings. As clinicians fine tune their approach to improving clinical outcomes to help decrease readmissions and, ultimately, enhance patient quality of life, it is important for them to remember the role that nutrition can play in this effort.

Malnutrition and readmissions

Nutritional status often takes a back seat to the main diagnosis and its related procedures and treatments. In 1974 Charles E. Butterworth Jr., MD, called out the widespread and often ignored malnutrition in hospitalized patients in his well-known article, The Skeleton in the Hospital Closet, published in Today’s Nutrition. Today, malnutrition continues to negatively impact both hospitalizations and readmissions. One-third of patients are already malnourished when they arrive at the hospital, and many continue nutrition decline—resulting in longer recovery, increased complication risk and readmission. Of those who are not malnourished, one-third will become malnourished during their hospital stay.

Malnutrition is a significant factor, as it is linked to:

  • Muscle wasting
  • Increased falls due to functional loss
  • Immune suppression with increased infection risk
  • Poor wound healing
  • Pressure sores

Comorbidities known to increase the risk of readmission include weight loss, iron deficiency anemia, renal disease, congestive heart failure and cancer. Weight loss alone correlates with a 26 percent increased risk of readmission. Gastrointestinal problems, infections, pain and sleep disturbances also contribute to readmissions.

Post-hospitalization assessment

After patients return from the hospital, extra attention toward the patients and their needs is an important step in helping prevent hospital readmission. Dietitians are encouraged to do a reassessment of each patient’s nutritional status, appetite and access to food. Updated lab results, medication changes, contact with family members and even hospital dietitians are considerations. Close attention to the post-hospitalization weight, changes in target weight and signs and symptoms of fluid overload are necessary. Sharing assessment results with the team, including any recommended changes in target weight, is an essential part of the post-hospitalization plan of care.

6 Important questions to ask patients

Because patients do not always report on eating issues that may significantly impact nutritional status, it is important to gather information related to their diet when they return to the dialysis center after hospitalization. The following six questions can help in assessing nutrient intake, food appeal and tolerance, and gastrointestinal issues.

  1. On a scale of 1 to 10, how is your appetite?
  2. How many meals and/or snacks are you eating in a day?
  3. What percentage of your meals or snacks are you eating?
  4. What foods are you eating?
  5. Are you experiencing nausea, vomiting, constipation or diarrhea? What issues are you experiencing, if any?
  6. What was your diet like in the hospital? How were you eating in the hospital?

Asking patients about appetite may seem simple but is of great importance. Patients who report poor or very poor appetite are at greater risk of hospitalization and death.

In addition to appetite, focusing on food availability post hospitalization can positively impact outcomes. Questions to ask patients include:

  1. Are you able to shop for food and/or prepare your meals?
  2. Where are you doing your grocery shopping?
  3. Do you have someone helping you with grocery shopping and meal preparation?
  4. What type of physical activity are you doing? Were you able to do these activities before your hospitalization?
  5. Are you able to afford your staple foods (including meat) after your hospital stay?

Home meal resources

Providing resources for patients who are unable to shop or prepare meals may help treat malnutrition or prevent further nutrition decline. There are programs in place that provide patients with meals after hospital discharge as part of the post-discharge plan. Some programs include insurance coverage for the meals. Renal meal delivery services include Mom’s Meals, Magic Kitchen and Martha’s Senior Gourmet. Meals on Wheels or locally sponsored programs may offer home delivery meals for renal diets as well. Dietitians and social workers together can explore resources in their local area and inform patients and caregivers about these resources.

Patient education handouts with information on dealing with poor appetite, gastrointestinal issues, easy to prepare meals and recipes are additional helpful meal resources.

Diet liberalization

The limitations of the renal diet can contribute to poor intake, especially when patients feel that many of the foods they like are taboo. During hospitalization, patients can miss meals due to tests and/or procedures, disliking the meals they are served, or receiving meals that have foods they were told not to eat due to potassium, sodium or phosphorus content. Nutrition decline may not be the time to instruct patients not to eat certain foods. A liberalized diet that encourages patients to eat whatever they can and includes nutrient supplements for extra calories and protein may be warranted. The provision of liberalized menus with simple meal and recipe suggestions can be helpful to both patients and caregivers. Increased lab monitoring during this time can help the care team monitor the impact of a liberal diet on nutritional status and electrolytes.

In summary, recovery nutrition plays a role in preventing hospital readmission. When decline in food intake or tolerance and advancing malnutrition is recognized and treated early, clinicians may be able to help keep patients at home. Assessing nutrition, sharing findings, paying attention to food availability, liberalizing the diet and asking patients about their ability to eat are actions that can make a difference.

Sara Colman, RDN, CDCES

Sara Colman, RDN, CDCES

Sara is a renal dietitian with over 30 years experience working with people with diabetes and kidney disease. She is co-author of the popular kidney cookbook "Cooking for David: A Culinary Dialysis Cookbook". Sara is the Manager of Kidney Care Nutrition for DaVita. She analyzes recipes and creates content, resources and tools for the kidney community. In her spare time Sara loves to spend time with her young grandson, including fun times together in her kitchen.

Maria Stasios, RDN, CSR, LDN

Maria Stasios, RDN, CSR, LDN

Maria Stasios, RDN, is a registered dietitian nutritionist with more than 25 years’ experience in clinical nutrition and management. She is a certified specialist in renal nutrition and currently works as a nutrition services manager at DaVita, where she supports and creates resources for dietitians working in patient care. Previously, she gained expertise in all aspects of medical nutrition therapy in a hospital setting, with a particular passion for working in critical care. She taught nutrition at the community college level and finds joy in working with young adult students.