The Impact of Continuity of Nutritional Care for Haemodialysis Patients from Acute to Community Setting. The National Kidney Foundation Singapore
Care Process & Redesign
AIC Community Care Excellence Awards
Agency for Integrated Care - Intermediate and Long Term Care
31 December 2024
Ensure at least 75% follow-up rate for community haemodialysis patients post-hospitalisation and post-nephrologist. Sustainability requires ongoing audits, training, and feedback to ensure adherence to structured nutritional care.
Year Submitted: 2024
Published Date: 31 December 2024
Tags: Care Process ＆ Redesign, Quality Improvement, Workflow Redesign
About this Content
Aims
Ensure at least 75% follow-up rate for community haemodialysis patients post-hospitalisation and post-nephrologist outpatient review. Show the impact of structured continuity of nutritional care with improvements in nutrition-related blood test markers (NBTM).
Background
Malnutrition is common in haemodialysis patients, leading to poor clinical outcomes. There was no structured approach for transitioning nutrition care from hospitals to community dialysis centres, increasing the risk of nutritional decline.
Methods
A structured workflow was established for acute hospital dietitians to send memos to community dialysis centre dietitians. Follow-up protocols were implemented for patients identified as malnourished or at risk.
Results
Follow-up rate achieved 100% (goal was 75%). 29 patients showed significant improvement in NBTM at four months post-baseline. Readmission rate within 30 days post-discharge reduced to 31% compared to 35% reported in literature.
Conclusion
Sustainability requires ongoing audits, training, and feedback to ensure adherence to structured nutritional care.
Lessons Learnt
Continuity of care improves patient outcomes. Regular reinforcement of workflows and comprehensive dietitian follow-up plans are key to sustainability.
Keywords
Malnutrition, Haemodialysis Patients, NBTM, Dietitian
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | Agency for Integrated Care - Intermediate and Long Term Care |
Organization(s) Involved | National Kidney Foundation |
Platform(s) | AIC Community Care Excellence Awards |
Healthcare Professional Group(s) | Allied Health |
Applicable Specialty or Discipline | Haematology, Nutrition ＆ Dietetics |
Project Lead(s) | Grace Liew |
Project Member(s) | Coryn Lee |
Connect with this contributor!
Tricica Oh - tricica.oh@nkfs.org
Project Attachment
49_NKF_CCEA_2024_The_Impact_of_Continuity_of_Nutritional_Care_for_Haemodialysis_Patients.pdf