Preventing Patient Hospitalization During the Holiday Season

With the holidays quickly approaching, it is vital to consider how we as clinicians can guide our patients through a healthy holiday season.

During the holidays, patients may struggle with eating foods that are higher in potassium and salt and drinking too many fluids, which may affect their health and lead to hospitalization. In addition to dietary concerns, treatment times and schedules may need to be adjusted. Patients may be traveling or have family visiting, which can impact their desire or ability to attend dialysis.

Some of the top reasons for hospitalization during the holidays are explored below. With the appropriate education and holiday schedule planning, hospitalization may be prevented or minimized.

Hyperkalemia

Dietitians and other clinicians should start discussions with patients now about the types of foods that may be safe for them to eat over the holidays.

Patients and medical staff may be confused about which foods contain potassium versus phosphorus. Some foods contain both. Potassium is an electrolyte commonly found in fruits and vegetables.

Common high-potassium holiday foods:

• Mashed potatoes
• Pumpkin and other winter squash
• Sweet potatoes and yams
• Banana or chocolate desserts
• Tamales and beans (especially when prepared Southern style)

Better choices:

• Rice, pasta, and noodles
• Homemade, not boxed, bread stuffing (also lower in phosphorus)
• Yellow crookneck squash
• Fruit pies, such as lemon, apple, blueberry, and cherry
• Mixed-berry fruit salads, including those with whipped cream, or trifles
• Vanilla desserts

If patients have higher potassium intake related to limited resources or cultural considerations, medications such as potassium binders may be prescribed to ensure potassium levels are within range, and dietary education can be provided to prevent hospitalization. Patients may also be referred to social workers or dietitians to help address food insecurity.

Finally, it is important to remind patients that reducing portion sizes is helpful when eating higher-potassium foods. By eating smaller portions and consuming a variety of fruits and vegetables, patients can enjoy a more healthy and balanced diet.

Fluid Overload

Schedule Changes

Dialysis holiday schedule changes to accommodate a holiday break for patients and staff can result in increased days without treatment and shorter treatment times. These changes can disrupt the patient’s rhythm and result in fluid gains. It is important to remind patients of these schedule changes in advance and discuss ways to alter their daily fluid intake.

Medications

Screening and evaluating prescribed medications such as diuretics for patients who still urinate may help with volume control, hypotensive or hypertensive episodes, and other excess fluid intake-related events. If patients are currently prescribed diuretics, it may be a good time to ensure prescriptions and dosing are current, and frequency of use should be adjusted for individual needs. The use of diuretics not only helps manage volume/fluid gains and blood pressure, but also has the added benefit of stabilizing potassium levels.

Sodium and Fluid Intake

It is helpful to guide patients toward making positive food choices and educate them to be conscious of sodium intake throughout the year. Sharing how to identify salt and high-sodium content in foods and what healthy options may look like is also important. Many high-sodium snacks will be readily available as family and friends gather for holiday celebrations.

Common high-sodium snack foods:

• Ham
• Canned and cured meats
• Pepperoni
• Cheeses
• Chips and crackers
• Dips, sauces, and gravies
• Pickles, olives, and relish tray condiments

Better choices:

• Chicken, turkey, or lean red meats
• Popcorn
• Low-sodium wheat or high-fiber crackers or pita chips
• Dips and spreads made with cream cheese and hummus, blended with fresh herbs and spices
• Homemade gravy without salt

Patients can also reduce salt consumption by using salt only at the table, not in cooking. Low-potassium fruits and vegetables can provide an alternative to salty snacks. When patients do eat higher sodium snacks, advise them to use small plates. Space for sides on dinner plates should be reserved for fruits and vegetables that provide a satisfying crunch.

Finally, remind patients to pay attention to their bodies when they eat so they will notice when they are experiencing an increase in dry mouth and thirst. By recognizing the symptoms of salt overconsumption, they may quickly recall which foods they ate so they can adjust next time.

Missing Treatment

Patients may miss treatment around the holidays for various reasons, such as schedule changes, transportation issues, visiting family, or diminished desire and energy to visit the clinic. The holidays are a difficult time for some patients. They may have feelings of depression, which can lead to withdrawal from social events or normal scheduled events such as dialysis. It is important to be in touch with patients’ feelings, emotions, and personal stories of loss connected to the holidays and refer them to social services if needed. Social services can help thwart or minimize their decline and potentially cut down on missed treatments.

Hypertensive or Hypotensive Episodes

Patients may present with excessive fluid gains or increased interdialytic weight gain because of the issues discussed above. It is important to discuss how excessive fluid gains, missed or shortened treatments, and not taking blood pressure meds as prescribed can adversely impact their health.

It is common for patients to experience either extremely elevated or critically low blood pressure when clinicians try to reduce these excess fluid gains. Many patients may not understand, remember, or be aware of these effects on the body, which require hospitalization to stabilize. It is especially difficult to allow patients additional days to dialyze the extra fluid with altered and shortened holiday schedules.

Providers must work as a team to help patients thrive during the holidays. The interdisciplinary kidney care team involves everyone from doctors, nurses, nurse practitioners, patient care technicians, dietitians, and social workers to administrative staff, and most importantly, the patient and their family.

In summary, patients should be reminded to take care of themselves. After all, who wants to be in the hospital during the holidays for something that is preventable?

Happy holidays to all!