Fast track dialysis: Improving emergency department and hospital throughput for patients requiring hemodialysis.

Abstract

To describe the impact of a novel communication and triage pathway called fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting to the emergency department (ED). Prospective and retrospective cohorts of ESRD patients meeting requirements of routine or urgent hemodialysis at a tertiary academic hospital from September 25th, 2016 to September 25th, 2018 in 1 year cohorts. Two sample t-tests were used to compare most outcomes of the cohorts with a Mann-Whitney U test used for skewed data. Nephrology group outcomes were analyzed by two-way ANOVA and Kruskal-Wallis and chi-square tests. There were 98 encounters in the historical cohort and 143 encounters in the fast track dialysis cohort. FTD had significantly lowered median ED LOS (4.05h, vs 5.3h, p<0.001), median hospital LOS (12.8h vs 27h, p<0.001), time to hemodialysis (4.78h vs 7.29h, p<0.001), and median hospital charges ($26,040 vs $30,747, p<0.016). The FTD cohort had increased 30 day ED return for each encounter compared to the historical cohort (1.85 visits vs 0.73 visits, p<0.001), however no significant increase in 1year ED visits (6.52 visits vs 5.80, p=0.4589) or 1 year readmissions (5.89 readmissions vs 4.81 readmissions, p=0.3584). Most nephrology groups had significantly lower time to hemodialysis order placement and time to start hemodialysis. A multidisciplinary approach with key stakeholders using a standard pathway can lead to improved efficiency in throughput, reduced charges, and hospital resource utilization for patients needing urgent or routine hemodialysis. A study with a dedicated geographic observation unit for protocolized short stay patients including conditions ranging from low risk chest pain to transient ischemic events that incorporates FTD patients under this protocol should be considered.