Background Optimizing volume status is central to hemodialysis care and may influence patient-reported outcome measures as recovery time. We evaluated the implementation of a structured decision aid (Recova) integrating symptom assessment with bioimpedance spectroscopy in routine hemodialysis practice.Methods A prospective multicenter pre-post within-subjects study was conducted in 10 Swedish hemodialysis clinics. Clinics adopted the intervention on a staggered schedule based on local readiness. Participants were assessed at baseline and after 12 weeks. Outcomes included bioimpedance spectroscopy-derived overhydration and extracellular water, patient-reported recovery time (hours to resume usual activities), and a fluid-related symptom score. Paired measurements were compared.Results Of 404 screened patients, 129 consented and 123 initiated the intervention. Recovery time data were available at both time points for 110 participants. Overhydration decreased from 2.6 +/- 1.7 to 2.3 +/- 2.0 L (p = 0.04) and extracellular water from 18.4 +/- 4.0 to 18.0 +/- 3.8 L (p = 0.01). Mean recovery time did not change significantly (6.7 +/- 7.1 to 5.8 +/- 6.2 h; p = 0.22) and median recovery time remained 4 h (IQR 1-10). Fluid-related symptom burden declined over the intervention period. No harms were reported; 13 participants did not complete the 12-week intervention.Conclusions In this multicenter pre-post evaluation, implementation of Recova was associated with modest improvements in bioimpedance spectroscopy-derived volume metrics and fluid-related symptoms, while recovery time did not change significantly. Controlled studies are needed to determine effectiveness and to identify which patients may benefit.