Implementing a Protocol for Incremental Hemodialysis in Incident Patients with ESKD: A Quality Improvement Project
Bibliographic record
Abstract
Background: Incremental hemodialysis (HD) is the process whereby the frequency of HD is adapted to the patient's residual kidney function, initially starting at twice a week with an increase based on clinical indications. Incremental HD potentially facilitates the transition to HD, reduces patient and caregiver burden, improves quality of life and reduces costs. We sought to increase the number of patients commenced on incremental HD at a tertiary care academic center and to develop a safe process to monitor these patients. Methods: We performed a prospective cohort quality improvement study. Starting November 1 2022, we aimed to start 75% of eligible incident chronic HD patients on incremental HD within 1 year. Eligible patients were defined as medially stable with no acute, active medical issues, and no indication for more frequent HD. The primary outcome measure was percentage of incident ESKD patients started on incremental HD. The balancing measure was the number of patients requiring transition to three-times per week HD. The incremental HD process was developed with input from all stakeholders. Results: Between November 1 2022 and March 31 2023, among 35 incident chronic HD patients, 14 were eligible for incremental HD, of which 9 started incremental HD. As of May 2023, 6 patients remain on two-times per week HD and 3 patients required an increase to three-times per week HD. The process developed included a) a patient information sheet about incremental HD b) nursing education, c) a nurse led protocol whereby the patient performs a 24 hour urine collection for volume and the nurse completes a safety checklist every 6 weeks, and d) an alert system for the MD to review the patient's HD prescription if they have uremic symptoms, are volume overloaded or hyperkalemic. Conclusions: We successfully initiated 64% of eligible incident HD patients on incremental HD, of which two-thirds remained on twice-weekly HD. Our next steps will involve feedback from patients and healthcare staff through quantitative and qualitative surveys with the goal of optimizing our protocol and expanding it to all dialysis units at our center.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.256 | 0.184 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.003 |
| Bibliometrics | 0.004 | 0.004 |
| Science and technology studies | 0.005 | 0.003 |
| Scholarly communication | 0.005 | 0.003 |
| Open science | 0.005 | 0.006 |
| Research integrity | 0.002 | 0.005 |
| Insufficient payload (model declined to judge) | 0.004 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".