Introduction: Undocumented immigrants are excluded from benefits that help compensate for scheduled outpatient hemodialysis (HD), compelling them to use emergency departments (ED) for HD. Consequently, these patients can receive “emergency-only” HD after presenting to the ED with critical illness due to untimely dialysis. Our objective was to describe the impact of emergency-only HD on hospital cost and resource utilization in a large academic health system that includes public and private hospitals. 

Methods: This retrospective observational study of health and accounting records took place at five teaching hospitals (one public, four private) over 24 consecutive months from January 2019 to December 2020. All patients had emergency and/or observation visits, renal failure codes (International Classification of Diseases, 10th Rev, Clinical Modification), emergency HD procedure codes, and an insurance status of “self-pay.” Primary outcomes included frequency of visits, total cost, and length of stay (LOS) in the observation unit. Secondary objectives included evaluating the variation in resource use between persons and comparing these metrics between the private and public hospitals.

Results: A total of 15,682 emergency-only HD visits were made by 214 unique persons, for an average of 36.6 visits per person per year. The average cost per visit was $1,363, for an annual total cost of $10.7 million. The average LOS was 11.4 hours. This resulted in 89,027 observation-hours annually, or 3,709 observation-days. The public hospital dialyzed more patients compared to the private hospitals, especially due to repeat visits by the same persons.

Conclusion: Health policies that limit hemodialysis of uninsured patients to the ED are associated with high healthcare costs and a misuse of limited ED and hospital resources.

Introduction: Triage functions to quickly prioritize care and sort patients by anticipated resource needs. Despite widespread use of the Emergency Severity Index (ESI), there is still no universal standard for emergency department (ED) triage. Thus, it can be difficult to objectively assess national trends in ED acuity and resource requirements. We sought to derive an ESI from National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items (NHAMCS-ESI) and to assess the performance of this index with respect to stratifying outcomes, including hospital admission, waiting times, and ED length of stay (LOS).

Methods: We used data from the 2010-2015 NHAMCS, to create a measure of ED visit complexity based on variables within NHAMCS. We used NHAMCS data on chief complaint, vitals, resources used, interventions, and pain level to group ED visits into five levels of acuity using a stepwise algorithm that mirrored ESI. In addition, we examined associations of NHAMCS-ESI with typical indicators of acuity such as waiting time, LOS, and disposition. The NHAMCS-ESI categorization was also compared against the “immediacy” variable across all of these outcomes. Visit counts used weighted scores to estimate national levels of ED visits.

Results: The NHAMCS ED visits represent an estimated 805,726,000 ED visits over this time period. NHAMCS-ESI categorized visits somewhat evenly, with most visits (42.5%) categorized as a level 3. The categorization pattern is distinct from that of the “immediacy” variable within NHAMCS. Of admitted patients, 89% were categorized as NHAMCS-ESI level 2-3. Median ED waiting times increased as NHAMCS-ESI levels decreased in acuity (from approximately 14 minutes to 25 minutes). Median LOS decreased as NHAMCS-ESI decreased from almost 200 minutes for level 1 patients to nearly 80 minutes for level 5 patients.

Conclusion: We derived an objective tool to measure an ED visit’s complexity and resource use. This tool can be validated and used to compare complexity of ED visits across hospitals and regions, and over time.