Background: Our region has the lowest hospital bed per capita of any metropolitan area in the United States. Additionally, during the COVID-19 pandemic there have been outpatient dialysis chair shortages due to workforce staffing issues. This has led to many patients waiting weeks or even months in the hospital to secure a new chair for community dialysis. These chair shortages have compounded other discharge barriers already exacerbated by the pandemic, further straining limited inpatient bed capacity.
Purpose: Our institution established a Hospital-at-Home program in November 2021 to care for acute care patients at home and thereby expand our inpatient capacity without building new hospital beds. Although Hospital-at-Home was designed for acute care hospitalizations, our leadership recognized the opportunity to maximize use of the virtual unit by caring for some inpatients awaiting a dialysis chair. This innovation would allow these patients to continue to receive dialysis in our inpatient unit while awaiting a community chair. In January 2022, our Hospital at Home program expanded to include patients on dialysis.
Description: Patients are transferred from the brick-and-mortar unit to the “virtual unit” in their home, which is comprised of technology, in-home clinicians and home-based services, all tethered to a 24/7 command center team. The inpatient dialysis unit provides dedicated time slots for these dialysis patients, reserving two slots in the morning and two in the afternoon on Tuesday (T), Thursday (Th), and Saturday (Sa). Prior to entry into the program, patients are converted to a T/Th/Sa schedule and a maximum of four dialysis patients are admitted to the program at a time. This program design maximizes continued flexibility of the dialysis unit to accommodate urgent dialytic needs of other hospitalized patients. The Hospital-at-Home paramedicine team provides round-trip transportation to the inpatient dialysis unit thrice weekly.
Conclusions: To date, the program has treated a total of 20 dialysis-dependent patients with an average length of stay of 34 days in the program. This has resulted in 690 acute care bed-days saved in the brick-and-mortar hospital by treating these patients at home. This program is an interdisciplinary collaboration between a virtual command center, in-home clinicians, inpatient Nephrology, and paramedicine transport. With collaboration and multidisciplinary support, Hospital-at-Home can be effectively leveraged to provide ongoing inpatient dialysis while addressing critical inpatient bed capacity shortages.