AquaTally: Improved Fluid Control for Dialysis Patients
Observational Trial Summary
Getting patients to follow their fluid restriction can be a challenge for nurses and dietitians in dialysis centers. Some patients have a difficult time tracking their fluid intake, underestimate how much they are taking in, or are simply not very aware of their intake. Many patients also feel that tracking their fluid intake is overly difficult and tedious. Patients struggling with fluid overload often times experience discomfort, longer dialysis sessions and adverse health effects. From a clinician’s perspective, these challenges mean that fluid overload patients can be concerning and require more care.
The AquaTally hydration tracking cup simplifies the task of hydration management throughout the day. The AquaTally, shown in Figure 1, simplifies the task of tracking by adding an indicator ring and numbers on the container. To track hydration users simply turn the white indicator ring to line up with the numbers on the AquaTally. The numbers 0-8 can either represent cups (8oz) or refills (16oz) depending on the person’s target. It is also very easy to track other fluid sources, like a glass of water at a restaurant, by adding the amount to the tally.
To find out if the AquaTally hydration tracking cup can help save staff time and make it easier for patients to manage their fluid restriction, AquaTally worked with in-center Registered Dietitians (RDs) at three dialysis clinics to conduct an observational trial. The purpose of this paper is to review the methods, results and conclusions of the trial.
The first step in developing the observation trial was to complete an internal evaluation of the AquaTally amongst the dialysis center staff. After this internal review and discussion, staff felt that the AquaTally had significant potential to justify a small trial and gained administrative permission. Staff decided to conduct the trial at three clinics for 30 days. The RDs would be the main point of contact for the trial and would conduct all of the direct patient interaction, and based on their knowledge, invite between 5-10 “high-gainers” at each clinic to participate in the trial. It’s important to note that the RDs deliberately invited patients who they felt were in a mindset to make a change. Patients were informed that they had the final decision on whether to participate and regardless of their decision it did not affect the care they would receive.
After patients agreed to participate they met one on one with the RD to discuss the trial, their particular fluid restriction, and to learn how the AquaTally works. It should be noted that the dietitians factored hydration from food sources into each patient’s fluid restriction. They also gave patients specific tips based on their condition and lifestyle.
The survey tool for the trial was developed with the support of researchers at the University of Arkansas in Fayetteville and edited by the RDs to fit their center’s terminology and processes. The survey tool was kept to ten questions and was designed to explore four areas: 1) significance of fluid restrictions to patients, 2) general product usability, 3) effectiveness as an aid to tracking and 4) preference relative to other methods they had used in the past. Nine of the survey questions were answered with either “Agree, Neutral, or Disagree” and the tenth question was open ended.
To collect the patient feedback, each RD interviewed patients after they had been using the AquaTally for approximately 30 days. Using this method helped make sure that patients understood every question, and it also provided the opportunity for the RDs to gather additional reactions from the patients about each question and the AquaTally in general. Following the trial period the RDs also filled out a survey and answered several short response questions. Before writing the trial summary, AquaTally set up phone calls with the RDs to discuss the trial results and the entire experience. These conversations were used in addition to the survey results to inform the analysis, the conclusions and future work.
Seventeen patients entered the trial, although, one selected to opt out in the first week. Sixteen patients, 9 women and 7 men between the ages of 36 and 82, completed the entire trial. All had a history of excessive Interdialytic Weight Gain (IDWG) and had been receiving dialysis for between 6 months and 4 years. The results of the final 16 survey responses for patients are shown in Figure 2 and those of the RDs are in Figure 3. Note that Question 3 in the patient survey and Question 4 in the clinician survey are stated in a reverse context. Patients reported drinking a wide range of fluids in the AquaTally, including water, juice, iced and hot tea, vodka, soda and ice (one full AquaTally of ice is about one cup or 8oz of water). One patient reported that they were not likely to drink coffee from the AquaTally because of the ridge by the rim.
As potential improvements, patients and staff suggested a more durable straw (two acrylic straws were broken during the trial), a flexible straw, a version with a “to go” or travel cover, and a version with more contrast on the numbering for darker colored drinks.
Subsequent to the survey, one site retroactively summarized the patients’ Interdialytic Weight Gain while using the AquaTally and compared the results to patients’ fluid gains for the month prior to the trial. The subset was made up of 8 patients whose average IDWG results are shown in Figure 4.
The average reduction in fluid gain was 0.66kg between sessions for 6 out of 8 patients (with a paired t-test statistic of 2.1%, i.e., a significant difference in the before and after average IDWG). Of the two patients who had higher fluid gains, one had missed sessions. The significant reduction in fluid gains for a majority of patients affirms patients’ positive survey answers in regards to questions 4 and 9 (Q4 – AquaTally made it easier to drink the right amount and Q9 –Compared to other ways of tracking AquaTally was most effective).
Overall, patients’ responses to the survey questions were extremely positive for significance, usability and effectiveness. The strong patient acknowledgement that they struggled limiting their intake prior to using the AquaTally affirms that the RDs selected an appropriate test group for the trial.
After using the AquaTally, 68% of patients agreed that the AquaTally eased the concerns they had about limiting their intake. In addition, 88% of patients agreed that using the AquaTally made drinking the right amount easier. Based on these responses, patients felt that the AquaTally made it easier for them to track their intake. From a usability perspective, the responses related to cleaning and use were positive. The biggest concern from patients was how easy it was to remove and replace the cover. It may be the case that patients with grip strength problems, potentially due to having a fistula, will need additional cover options. The RDs also acknowledge that covers may be more challenging for some patients regardless of the design.
The results of the RDs’ surveys and the post-trial interviews showed strong support for having the AquaTally available as a coaching tool for patients who struggle with fluid gains. In the survey responses, 100% of the RDs agreed that the AquaTally simplified managing patients’ hydration, was easy to explain to patients and overall improved patients’ compliance. In addition, 100% of RDs reported that the AquaTally made educating patients about their restriction easier.
One RD remained concerned about the challenges that patients live with regarding fluid restrictions, which is understandable given the severity of many patients’ conditions. The cost of purchasing AquaTallys for each patient was also a concern. In most cases there is not a specific clinic budget for purchasing containers for patients, but it’s also not feasible for patients to purchase themselves. Clinics will have to evaluate if purchasing AquaTallys for high gainers will provide enough benefit by increasing patients’ quality of life and lowering the staff resources and time that high gainers may require due to their longer run times and follow up.
A large part of motivating patients and reducing patient denial is raising their awareness of fluid intake. If patients can track their intake and see that it is much higher than they thought, it makes denying that their fluid intake is high more difficult. Obviously, the point of tracking and raising awareness isn’t to prove patients wrong. Instead, it can be a great opportunity to start talking to patients about their intake in a context that isn’t challenging. If the patient can begin to improve their compliance, they will likely see a reduction in the negative symptoms that come with fluid overload. The reduction in symptoms is a positive affirmation for patients that improving compliance equals an improvement in their quality of life.
Overall, the observational trial showed that the current version of the AquaTally has strong potential to help patients who are struggling with fluid intake. The results suggest that the AquaTally can make educating patients on their fluid intake easier and more efficient. Both AquaTally and the RDs feel that the AquaTally cup is a promising assistive device for patients who are struggling with their fluid intake and are willing to try a new technique.
AquaTally would like to thank the center dietitians Jonathan Belknap, RD, Leah Wessinger, RD, LDN, CDE and Nancy Coulehan, RD, CDE as well as the nurses and patients for participating in the observational field trial. We greatly appreciate your support in working to develop a simple and effective coaching tool to make managing fluid restrictions easier.
AquaTallys were provided free to the clinics. No trial participants were compensated. All participation was completely voluntary.
AquaTally would also like to thank Dr. Matthew Ganio and his research team at the University of Arkansas Fayetville for their assistance in creating the survey and ongoing support in understanding hydration and study design.