a b s t r a c t

Objective: 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 dis- ease (ESRD) patients presenting to the emergency department (ED).

Methods: Prospective and retrospective cohorts of ESRD patients meeting requirements of routine or urgent he- modialysis 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.

Results: There were 98 encounters in the historical cohort and 143 encounters in the fast track dialysis cohort. FTD had significantly lowered median ED LOS (4.05 h, vs 5.3 h, p < 0.001), median hospital LOS (12.8 h vs 27 h, p < 0.001), time to hemodialysis (4.78 h vs 7.29 h, 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 1 year 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.

Conclusion: 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.

(C) 2021

1. Introduction

Patients with end stage renal disease (ESRD) use emergency services up to six times more than an average adult. These visits lead to approx- imately 1.7 hospital admissions per patient per year [1-3], which ac- count for over 33% of all Medicare hemodialysis expenditures and are associated with worse health outcomes for these patients including

* Corresponding author at: 2711 Tallulah Dr. NE, Brookhaven, GA 30319, United States of America.

E-mail address: [email protected] (C. O’Donnell).

mortality and increased hospitalization [2,4-8]. The need for urgent he- modialysis is typically determined in the emergency department (ED) and requires admission to an emergency department observation unit (EDOU), to a hospital medicine service observation unit (HMSOU), or to an inpatient bed either in observation or inpatient status. There are decreased Healthcare costs associated with Observation Units that use protocol-based interventions [9]. These units are increasing in preva- lence due to an estimated savings of up to 1.3 billion dollars per year as a response to the increased amount of Medicare spending under ob- servation status, especially for the ESRD population presenting with

https://doi.org/10.1016/j.ajem.2021.02.035

0735-6757/(C) 2021

fluid overload [10-14]. Focusing on throughput and length of stay on ob- servation patients is a way to further decrease these costs.

At our local institution, urgent and routine hemodialysis patients were managed by the hospital medicine service (HMS) under observa- tion status in a HMSOU. They were cared for by an advanced practice provider (APP) who was supervised by a physician. The average length of stay for patients needing hemodialysis averaged 24 h. Inefficient communication between healthcare providers was thought to be a pri- mary cause of these long lengths of stay. These patients were not iden- tified early to prioritize their hemodialysis treatment and would often be admitted late in the day after a long ED length of stay. Lack of sched- uling prioritization often resulted in an avoidable hospital day due to lack of a late day hemodialysis shift assignment.

• 1. Goals of this investigation

Our objective was to create a novel identification and communica- tion pathway called Fast Track Dialysis (FTD) for low-risk ESRD patients to reduce their ED and hospital length of stay throughout the continuum of care. We created a protocol to expedite throughput to hemodialysis via rapid identification in the waiting room, obtaining necessary diag- nostics in the triage area and bypassing the acute care setting of the ED. We hypothesized that improved identification and triage of low-risk ESRD patients and improved communication using a defined protocol would reduce hospital length of stay by shortening time to he- modialysis, as well as decrease overall hospital charges and hospital re- source utilization.

1. Material and methods
   1. Study setting and population

Our institution is an urban 537 bed tertiary care center in which hospitalists care for approximately 80% of the medical admissions and 95% of the admissions for patients with ESRD. The emergency depart- ment volume compromises over 63,000 encounters annually. Our hos- pital has a sixteen-bed hemodialysis unit that is operational for 12 to 18 h a day starting at 7 am for routine and urgent hemodialysis with emergent cases performed bedside in the intensive care units. Hemodi- alysis for hospitalized patients routinely occurs in this pattern Monday through Saturday with only emergent cases occurring on Sundays when an on-call nurse is called into the hospital.

All patients with ESRD on hemodialysis age greater than 18 years old who were considered low risk by ED clinical criteria, hemodynamic pa- rameters, and electrocardiogram criteria were deemed eligible for the pathway (Fig. 1). Some patients were excluded due to Clinical concern for pathology that would not be fully addressed by hemodialysis such as cardiac chest pain. Patients were also excluded if they had a fistula or graft requiring a procedure or surgery. All patients were admitted to the hospital medicine service and had a nephrologist consult to pro- vide hemodialysis orders in both cohorts. Two nephrology groups (A and B), which compromised approximately 60% of the consultative services for ESRD patients, were selected for the pilot phase which spanned the first three months on the intervention. Subsequently, FTD was expanded to include a total of four nephrology groups at our hospi- tal starting in December 2018. One private nephrologist elected not to join the initiative.

• 1. Cohorts

The historical cohort had a geographically located HMSOU managed by an advanced practice provider (APP) supervised by a physician from September 25th, 2016 through September 24th, 2017. The process for the historical cohort was as follows: ESRD patients were checked into the waiting room, assessed in the triage area, and returned to the waiting room until an acute ED bed was assigned, then an EKG and

laboratories were drawn. Once EKG/labs were reviewed, the patient was assessed by the ED team, and the nephrologist was contacted re- garding recommendation for outpatient hemodialysis or admission for urgent hemodialysis. If urgent hemodialysis was recommended, the hospitalist team was then contacted for admission orders to the HMSOU. The FTD cohort had a hospital medicine service dedicated short stay team (length of stay anticipated to be less than 48 h) com- posed of two APPs supervised by a physician from September 25th, 2017 through September 24th, 2018. Both cohorts had 4 separate ne- phrology groups involved: one large academic affiliated group (A), a large private group (B), a small academic affiliated group (C), and one smaller private group (D). The large academic group consisted of an at- tending physician working alongside either an APP or fellow, whereas the other groups were composed of only an attending physician.

• 1. Study protocol

A taskforce composed of hospitalists, emergency department physi- cians, nephrologists, and hemodialysis nurses developed a novel com- munication and patient flow pathway called Fast Track Dialysis. This pathway identified and prioritized low-risk ESRD patients in the triage area of the emergency department and created a scripted communica- tion and patient flow pathway. There was a dedicated line of communi- cation between the ED, nephrologists and hemodialysis unit to ensure that there was a hemodialysis chair available for a prioritized FTD pa- tient. This process minimized unnecessary chest X-rays and laboratory tests. It utilized scripted communication to facilitate admission to a hos- pitalist service and transfer from the ED to the hemodialysis unit, followed by Discharge home. Hemodynamic criteria were based on the local rapid response criteria and as well as the criteria used by the local hemodialysis outpatient units. Patients could enter the pathway if they met the following criteria: 1) Systolic blood pressure less than

200 mmHg, 2) Diastolic blood pressure of less than 100 mmHg,

3) Heart rate less than 120 beats per minute, 4) Oxygen requirement less than 4 L per minute, 5) Potassium level less than 6.5 mEq/L, 6) No EKG changes concerning for ischemia or Severe hyperkalemia, 7) No he- modialysis access issue that would require Vascular Surgery or Inter- ventional Radiology intervention, and 8) No clinical suspicion of another active process such as cardiac chest pain or infection by the ED providers. Nephrologists had the discretion to decide for the patient to be transported to their outpatient clinic as opposed to observation in the hospital in both cohorts. Timing was limited to arrival to the emer- gency department during the daytime hours (5 am to 5 pm). This time- frame allowed for hemodialysis bed assignment as the unit opened to take patients at 7 am and assigned its last patients for its nighttime third shift at 5 pm. In both cohorts there was an electronic admission order set called “HD OBS” that was used for admission orders. Patients were transported straight to the hemodialysis unit without utilizing an ED bed from this triage area. The hospital medicine service per- formed an admission history and physical on the hemodialysis unit and then discharged from the assigned observation bed once the hemo- dialysis was complete.

• 1. Data collection and outcome measures

This was a prospective and retrospective chart review. Data was col- lected through the healthcare system’s data warehouse. Historical pa- tients were selected based on the objective exclusion criteria on the FTD pathway to match the prospective interventional cohort. Patients were excluded if the clinical picture warranted more than one session of hemodialysis or they had an active medical condition such as cardiac chest pain or an infection which would necessitate further diagnostics and evaluations. A chart review of ED provider, admission history and physical, nephrology consult note, and discharge summary was per- formed by three authors to assess the remaining cohort to ensure that clinical eligibility was met. Discrepancies were adjudicated with a 3rd

Fig. 1. Fast Track Dialysis Pathway.

reviewer. The primary outcomes were emergency department length of stay, total hospital length of stay, and hospital charges. Secondary out- comes were ED arrival time to placement of hemodialysis orders and ED arrival time to start of hemodialysis (to approximate nephrology re- sponsiveness) as well as time from discharge order to hospital depar- ture. The start time for all timing metrics other than discharge order to hospital departure was at ED registration. Subgroup analyses by ne- phrology service were performed. This study was approved through the affiliated university’s Institutional Review Board (#97259).

• 1. Data analysis

Two-sample t-test or chi square test was used to compare demo- graphics and outcomes by study period. For skewed outcomes like charges and overall LOS, a Mann-Whitney U test was used to compare differences in the distribution. For the readmission/revisit data, a Mann-Whitney U test was used, and bootstrap confidence intervals were calculated due to the skewness of the data. A two-way ANOVA tested the interaction of the effect of Nephrology group and FTD time period on secondary outcomes (time to hemodialysis or orders). Kruskal-Wallis tests were used to compare the distribution of continu- ous outcomes by Nephrology group and the Holm test was used for pairwise p-values to account for multiple testing comparisons. Statistical analysis was performed using R 3.6.0, with p < 0.05 representing statistical significance [15].

1. Results

A retrospective chart review via ICD 10 codes showed there were 4502 encounters of ESRD patients in the historical control. 280 of these encounters met objective criteria. A review showed 98 encounters where the patient only required hemodialysis with no other active medical concerns. 82 of the 98 were individual patients. There were 13 encounters that were adjudicated in the historical cohort. In the

interventional cohort there were 4803 encounters with ESRD patients of which 143 were placed on the FTD pathway with 93 being individual patients (Fig. 2).

Characteristics of the two cohorts are compared in Table 1. The FTD intervention cohort had higher blood pressures on triage vital signs. This was the only significant difference between the cohorts. The ICD 10 admission diagnoses were grouped into five main categories. The top three ICD 10 diagnoses were consistent in both cohorts: hemodial- ysis need, Respiratory insufficiency, and hemodialysis access problem. There was significantly less chest x ray use in the FTD cohort. The re- mainder of the demographic and objective markers were consistent among the two groups including age, potassium level, and other vital signs (Table 1).

The outcomes of the different cohorts are compared in Table 2. The FTD intervention significantly lowered our primary endpoints of me- dian ED LOS versus the historical cohort (4.05 h vs 5.30 h) and median hospital length of stay (12.8 h vs 27 h) as well as median charges ($26,040 vs. $30,747). In terms of secondary endpoints, FTD signifi- cantly lowered median time to hemodialysis orders and the median time to receive hemodialysis. There was an increase in the median time between the discharge order and hospital departure time in the FTD intervention compared to the historical cohort as well as 30-day ED return visits. There was significantly increased 30-day ED return visits from each encounter in the FTD group but no significant change in repeat ED visits 1 year from each encounter nor in Hospital readmissions (Table 2). The average length of stay for all hospital med- icine patients in the historical cohort was 5.32 days and the average length of stay in the FTD cohort for all hospital medicine patients was

5.21 days.

The FTD pathway significantly lowered the time to hemodialysis order placement as well as time to obtain hemodialysis for most of ne- phrology groups. When groups were compared among themselves to see if one had a more significant improvement with the FTD pathway no differences were observed (Figs. 3 and 4). In the FTD intervention,

Fig. 2. Enrollment schema for FTD.

Table 1

Patient characteristics

Variable	Historical	FTD	p
	(n = 82)	(n = 93)
Age, M (SD)	57.0 (13.9)	55.8 (12.5)	0.54
Gender, n (%)			0.98
Female	36 (43.9)	41 (44.1)
Male	46 (56.1)	52 (55.9)
Race, n (%)			0.44
African American or Black	80 (97.6)	88 (94.6)
Asian	1 (1.2)	0 (0.0)
Caucasian or White	1 (1.2)	1 (1.1)
Multiple	0 (0.0)	2 (2.2)
Unknown, Unavailable or Unreported	0 (0.0)	2 (2.2)
Ethnicity, n (%)			0.08
Hispanic or Latino	0 (0.0)	4 (4.3)
Non-Hispanic or Latino	81 (98.8)	89 (95.7)
Unreported, Unknown, Unavailable	1 (1.2)	0 (0.0)
First K (mEq/L), M (SD)+	5.01 (0.86)	4.96 (0.87)	0.71
Triage HR, M (SD)	82.9 (13.2)	81.5 (13.2)	0.46
Triage RR, M (SD)	18.5 (2.0)	19.1 (4.1)	0.28
Triage SBP (mmHg), M (SD)	151.9 (27.1)	162.2 (32.5)	0.02?
Triage DBP (mmHg), M (SD) Chest X ray at Admission, n (%)	81.9 (12.5)	88.5 (19.4)	0.008? <0.001?
No CXR	24 (24.5)	66 (46.2)
Admission CXR	74 (75.5)	77 (53.8)
Diagnosis

Insurance, n (%)++			0.45
Private	14 (17.1)	25 (26.9)
Public	66 (80.5)	59 (63.4)
Military/WC/Misc.	0 (0.0)	1 (1.1)
None	2 (2.4)	8 (8.6)

FTD = Fast Track Dialysis; K = Potassium; HR = Heart Rate; RR = Respiratory Rate; SBP = Systolic Blood Pressure; DBP = Diastolic Blood Pressure; WC = Workman’s Compensation.

Hypertensive crisis	2 (2.4)	4 (4.3)
Hemodialysis Access Complication	7 (8.5)	11 (11.8)
Infection	2 (2.4)	1 (1.1)
Hemodialysis need	36 (43.9)	39 (41.9)
Other	10 (12.2)	8 (8.6)

* Statistically significant p < 0.05

⁺ 7 Post FTD patients missing Potassium data

⁺⁺ P Value compares categories Private, Public, Other by Time period

Table 2

Outcomes by patient group

1. Discussion

To the best of our knowledge this is the first evaluation of an inter- vention designed to improve throughput and subsequent ED and hospital LOS for ESRD patients in need of routine or urgent hemodialysis when they present to the emergency department. We found that having a Multidisciplinary team with key clinical stakeholders involved in the development of a care pathway led to reduced ED LOS, hospital LOS and charges associated with routine and urgent hemodialysis for ESRD patients. ESRD patients in the ED account for high hospital and ED utili- zation and represent 33% of Medicare ESRD costs [1,16]. The costs asso- ciated with the ESRD population in the US were over 40 billion dollars in 2009 [17]. Our data also shows that the decreased length of stay is supe- rior to the natural decrease of length of stay that occurred during this timeframe on the hospital medicine service. We reduced length of stay by approximately one half of a day compared to a tenth of a day for all hospital medicine patients. The improvement was despite having a structural process change with the loss of the geographically locatED observation unit which we feel may have affected the efficiency of the post hemodialysis length of stay.

We found that using this communication pathway to identify and prioritize care for this population improved the outcomes measured for all the nephrology groups. This pathway was used for patients with- out hemodialysis centers for more routine hemodialysis including those that were uninsured, awaiting Medicare with their new ESRD status, and those who moved or were travelling to the state and did not establish a hemodialysis clinic. Despite having increased 30-day ED re- turn visits for the FTD cohort compared to the historical one, there was no increase in the median number of readmissions or 1-year ED re- turn visits. This shows that for patients that have no hemodialysis center this is a crucial pathway for hemodialysis. Moreover, once a center is established, they do not have any increase in repeat utilization com- pared the historical control. This implies compliance with their hemodi- alysis center and not a preference on ED based hemodialysis.

Additionally, we found one patient in the intervention group who was undocumented whose only hemodialysis means was through this program. This resource utilization pattern is common in the United States where approximately 6500 undocumented im- migrants use emergency departments as their primary hemodialysis centers [18]. After starting the program, we only had one inpatient encounter lasting three days for this patient, which was important as undocumented ESRD patients with ED based hemodialysis have

Variable Historical

(n = 98)

FTD p

(n = 143)

ten times the amount of inpatient stays compared to documented patients and a 3 to 14 times higher mortality [5,19]. Given that 40

Charges ($), Median (IQR)⁺ 30,747 (14,482) 26,040 (14,114) 0.016?

ED LOS (hrs.), Median (IQR) 5.30 (3.68) 4.05 (2.42) <0.001?

LOS (hrs.), Median (IQR) 27.0 (17.9) 12.8 (18.7) <0.001?

of 50 states in America do not allow for scheduled hemodialysis for undocumented immigrants and emergency-only hemodialysis

has shown increased costs for Hospital systems [8], we feel that

Time to Hemodialysis order, Median (IQR)

Time to Hemodialysis, Median (IQR)

DC order to Hospital Departure (no AMA) Median (IQR) (min)⁺⁺

4.28 (5.85) 2.79 (2.46) <0.001?

7.29 (14.35) 4.78 (3.58) <0.001?

1.91 (2.61) 2.44 (3.66) 0.0123?

this pathway could allow increased efficiency in the healthcare sys- tem for this population.

One of the unique aspects of the pathway that the authors feel could be adapted at other institutions is offloading the acute ED beds. Prior to FTD, ESRD patients would need to be seen in an acute ED bed after the

30-day ED visits, M (SD) 0.73 (1.08) 1.85 (2.38) <0.001

1-yr ED visits, M (SD) 5.80 (6.51) 6.52 (7.03) 0.4589

1-yr Readmissions, M (SD) 4.81 (5.28) 5.89 (6.37) 0.3504

LOS = Length of Stay; AMA = Against Medical Advice.

* Statistically significant p < 0.05.

⁺ Based on 97 historical and 141 actual patients with billing data available.

⁺⁺ Based on 93 historical and 140 actual patients who are not AMA.

the nephrology groups showed some differences in outcomes with Group D having significantly lower charges and Group A having lower hospital and ED length of stay (Table 3).

triage assessment and then await laboratory tests to be drawn before they were assessed for hospital-based hemodialysis or transported to their outpatient clinic. With FTD, some common “wait time” is elimi- nated as the assessment happens in the waiting room. We did not re- quire telemetry or IV access for patients and had a quick transition from the waiting room to hemodialysis, reducing chest x rays and re- source utilization. Patients are transferred to a triage area from the waiting room for a readily available venous blood gas with electrolytes, which can accurately assess the potassium level in a little as ten minutes while a confirmatory laboratory is sent in some cases [20]. Serum potas- sium levels for FTD patients were normal on average in our study. A con- servative potassium level threshold of <6.5 mEq/L was used to mitigate cardiac arrhythmia related adverse events. It is conceivable that a higher

Fig. 3. Time to Hemodialysis Orders per Nephrology Group. *: p <= 0.05. **: p <= 0.01. ***: p <= 0.001. ****: p <= 0.0001. Legend: The boxplot visualizes summary statistics. The ends of the box are the first quartile and third quartile. The median is marked by a horizontal line inside the box. The upper whisker extends from the hinge (3rd quartile) to the largest value no further than

1.5 * IQR from the hinge (where IQR is the inter-quartile range, or distance between the first and third quartiles). The lower whisker extends from the hinge (1st quartile) to the smallest value at most 1.5 * IQR of the hinge. Any observation beyond 1.5*IQR of the 1st or 3rd quartile are outliers denoted with a point.

potassium level threshold could be used in the future if the barrier of not having cardiac monitoring available in triage could be addressed.

A strength of our study is that it included a large population of ESRD patients in a large urban hospital. We used a prospective cohort and met

monthly to ensure that the pathway was being followed and used mul- tiple education and feedback sessions among the ED, HMS, and nephrol- ogy faculty to ensure that the appropriate patients were placed on the pathway. Nephrology groups C and D joined the study after a

Fig. 4. Time to Hemodialysis per Nephrology Group. *: p <= 0.05. **: p <= 0.01. ***: p <= 0.001. ****: p <= 0.0001. Legend: The boxplot visualizes summary statistics. The ends of the box are the first quartile and third quartile. The median is marked by a horizontal line inside the box. The upper whisker extends from the hinge (3rd quartile) to the largest value no further than 1.5 * IQR from the hinge (where IQR is the inter-quartile range, or distance between the first and third quartiles). The lower whisker extends from the hinge (1st quartile) to the smallest value at most 1.5 * IQR of the hinge. Any observation beyond 1.5*IQR of the 1st or 3rd quartile are outliers denoted with a point.

Table 3

FTD outcomes by nephrology group

Variable	A (n = 51)	B (n = 49)	C (n = 6)	D (n = 37)	p
Charges ($), Median (IQR)+	26,578 (14,012)	28,048 (17,176)	24,422 (10,933)	21,787 (10,929)	0.16?
ED LOS (hrs), Median (IQR)	3.27 (3.18)	4.13 (1.95)	4.36 (0.39)	4.83 (2.33)	0.01?
LOS (hrs), Median (IQR)	10.8 (4.1)	24.4 (22.4)	18.8 (16.9)	13.9 (21.6)	<0.001?

FTD = Fast Track Dialysis; LOS = Length of Stay.

⁺ Removed 2 encounters with no charges.

* statistically significant p < 0.05 between groups.

three-month pilot period which could explain their lower encounter numbers. Despite their joining three months after the intervention began, we feel that the reductions of our primary measures (LOS, ED LOS, and charges) are generalizable to multiple institutions as both var- ious sized academic and community-based nephrologists showed im- proved metrics compared with historical cohorts. Our protocol emphasized communication between the emergency department and nephrology teams with an early call to the nephrologist during the ED presentation to expedite transfer to the hemodialysis unit. Therefore, the protocol can be easily adapted to only settings where ESRD patients are managed in an EDOU or in acute care emergency department beds. This effect is shown by the narrowing of the confidence intervals and overall decrease of the median ED arrival time to hemodialysis orders. The FTD pathway had ten patients with LOS greater than 48 h which suggests that they may have been mis-triaged onto the pathway. How- ever, there was only a 7% conversion to inpatient status. Observation units historically have a 10-30% admission rate [21-23]. With a lower admission rate, we feel that the patients were appropriately triaged, and that the hemodynamic parameters are safe boundaries. Addition- ally, there was only one patient in the FTD cohort that needed to be

transferred to the ICU for further management and treatment.

The FTD cohort had a significantly increased time from discharge order to hospital departure time compared to the historical cohort that was unanticipated. The historical cohort of patients were treated in a geographically located ten bed HMSOU run by an APP. Since this care environment could not be fully replicated due to closure for reno- vations during the intervention cohort study, the true impact on this outcome could not be demonstrated. Following the unit closure, FTD pa- tients were assigned to acute care beds on two dedicated nephrology floors under Observation status. This led to delays for discharged pa- tients who would first need a physical bed assigned and then be trans- ferred to that location before the discharge process could be completed with nursing giving discharge instructions. In fact, the three patients that left against medical advice in the FTD cohort left due to frustration awaiting a bed assignment. Studies will show that a dedicated observa- tion unit, whether emergency department-run or HMS-run leads to in- creased efficiency, decreased LOS, and cost savings [24]. Our historical cohort acted as a type 1 unit (closed with hardwired protocol) which often has the highest evidence for favorable outcomes. The FTD cohort acted more as a type 3 unit (not closed and with a protocol) which is more consistent with hospitals across the United States [24]. Across the United States two thirds of observation patients are not in a geo- graphically located unit [9,13]. The authors feel that FTD patients housed in a geographically located unit would lead to increased effi- ciency in the care of patients and reduction in discharge order to hospi- tal departure time. We hypothesize that experienced, dedicated observation unit nurses are more focused on discharge and bed turn- over as opposed to regular floor nurses which could improve efficiency.

• 1. Limitations

There are several limitations to our study. One limitation was that the historical cohort was identified by retrospective chart review at a single academic site. The charts were first evaluated based on objective

parameters derived from the FTD inclusion criteria. A manual chart re- view followed based on the consensus of three independent reviewers, with the third adjudicating any differences between the first two. This process was set up to reduce selection bias as much as possible. The main reasons for clinical elimination were vascular access complications of grafts and fistulas, concern for active chest pain, and infection. These were consistent elimination criteria for FTD. There is an inherent review bias associated with this retrospective review as we selected observation-only patients and could not account for patients who possi- bly had to be moved to the intensive care unit for emergent hemodial- ysis. Thus the patients selected may have been lower acuity. The increase in the number of patients in the FTD cohort could be attributed to an inherent clinical bias among providers who knew there was a new and more efficient process in place. Patients were directed to FTD versus being discharged from the ED to their outpatient unit. Another explana- tion could be that there was a secular trend during this time frame of in- creased ED volume and hospital admissions. A factor related to patient flow that we could not accurately measure was utilization of ED and Hospital resources, especially related to other service lines such as surgery. As the ESRD patient was quickly identified and transported to hemodialysis from the triage area and then quickly discharged, re- sources were made available for another patient. It would have been in- teresting to evaluate whether all patients seen in the ED had improvED throughput due to our system.

An additional limitation of the study was that we could not assess

certain data points that would have created a more comprehensive evaluation. One of those data points is costs associated with the hospi- talization due to limited data retrieval. Hospital charges vary among in- stitutions and Geographical area and are not a specific marker that can be used for cost savings [25]. Another data point is patient attitudes to- wards the intervention which limits any evaluation of FTD from the patient’s perspective. Future studies should engage patient satisfaction and compare different types of observation units to see if a geographic change to a closed unit can improve patient satisfaction and outcome measures.

1. Conclusion

Fast Track Dialysis is a novel pathway that uses clinical and objec- tive screening criteria in the emergency department and a dedicated communication pathway to help identify and facilitate earlier treat- ment for patients in need of urgent and routine hemodialysis. This pathway improves ED and hospital throughput and resource utiliza- tion. We have shown decreased length of stay across the hospital con- tinuum, decreased charges, and decreased ED arrival time to hemodialysis. The results may be generalizable to many institutions with or without EDOUs or HMSOUs and with a variety of nephrology groups. There may be a benefit to unique populations such as the un- documented and uninsured. We feel the next step would be to evalu- ate the pathway in a Type 1 closed observation unit to determine if further efficiencies would be gained in ED and hospital LOS with re- duced departure time. This study shows that a relatively simple iden- tification and communication pathway is associated with improved patient and hospital outcomes.

Financial support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Presentations

This work has been presented in podium format at the Society of Ac- ademic Emergency Medicine in Indianapolis IN on May 2018 as well as in poster format at the Society of Hospital Medicine Annual Conference in Orlando FL, the American College of Physicians National Conference in New Orleans LA, the Society of General Internal Medicine Denver CO all in April 2018 and the American Society of Nephrology meeting in San Diego CA in October 2018.

Declaration of Competing Interest

The Authors report no conflicts of interest in regards to this work.

Acknowledgements

We would like to thank Vena Crichlow, James Capes MD, Daniel Lesky MD, and Anwar Osborne MD, whose contributions were instru- mental in the development and analysis of FTD.

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