Background: Due to significant HD nursing shortages complicated by the COVID-19 pandemic, available outpatient hemodialysis chairs have become scarce. This results in prolonged length of stay for these patients, staying in the hospital for months. Not only is this a problem for the healthcare system dealing with capacity issues and reimbursement, the patients remain inpatients in a hospital when they could live outside of the hospital. This problem is a national one, as the number of people living with ESRD is increasing.
Purpose: The purpose of this innovation is to create a discharge process for these patients with coordinated pathways to facilitate HD via emergency department (ED) while waiting for in-center HD assignment presents a viable alternative. Such a solution would need to be efficient, safe, reliable, patient centered, and cost effective. A flag within the Electronic Health Record (EHR; EPIC) identifies enrolled patients and provides decision support to ED triage providers. Patients presenting for HD without other acute need are not roomed nor admitted. Patients are promptly evaluated by nephrology and transported to the inpatient dialysis unit, bypassing labs and IV placement if appropriate. Once dialysis is completed, the patient is safely discharged home through the ED observation team. Routine labs and ESRD-related medication administration simulates in-center HD unit protocols. Monthly inter-professional meetings are held to review the panel of enrolled patients, investigating opportunities for care improvement, and mitigating any barriers to eventual in-center assignment. Social work support robustly attempts to place the patients in an outpatient dialysis center, as the ED notes relate compliance, supporting this initiative.
Description: We enrolled 14 individual patients between May 1st and Nov 1st, 2022. Of these, 6 (43%) are considered unlikely to be placed for in-center HD due a history of regional denials due to mental health or medical comorbidities. 3 (21%) have substance use disorder, complicating placement. 4 (29%) have secured in-center assignments in the 6 months.Total encounters for HD have increased from 18/month in May to 58/month in October. During the most recent month of the program (Oct 2022), only 5 (8.6%) of encounters resulted in hospital admission; the time from triage to renal consult order was less than 30 minutes for 38% of encounters; and time from arrival to discharge was less than 12 hours for 95% of encounters (average total time 9.07 hours). Adherence rates, defined as percent of goal 3x/weekly treatments attended while accounting for admissions, ranged from 42 to 75% (not accounting for HD received at other local institutions, or admissions outside the Jefferson system). Financial analysis revealed net revenue $678,363, total direct costs $632,882, with a positive contribution margin of $86,634. There have been no co-pays charged or collected from the patients in this cohort to date.
Conclusions: Early evaluation of the program has focused on 1) efficiency: time from presentation to nephrology consult (target < 30 minutes) and total time from presentation to discharge order (initial target < 12 hours); 2) safety: patient receipt of HD 3x weekly while enrolled; and 3) cost effectiveness: aiming for financial neutrality for patients (evaluation of co-pays) and the health system (cost vs reimbursement for HD visits).