TELENEPHROLOGY: EXPERIENCE CARING FOR HOSPITALIZED PATIENTS IN A RURAL COMMUNITY HOSPITAL (1,978 VISITS OVER 2 YEARS)
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2 TELENEPHROLOGY: EXPERIENCE CARING FOR HOSPITALIZED PATIENTS IN A RURAL COMMUNITY HOSPITAL (1,978 VISITS OVER 2 YEARS) Using Telemedicine for the care of Renal Patients (ESRD and CKD) at a Rural Regional Medical Center in Missouri As presented to the American Society of Nephrology in a peerreviewed session, November Specifics for methods, results and outcomes Presented by: Jerome S. Tannenbaum, M.D., Ph.D., FACP CEO Sanderling Renal Services USA LLC, Nashville, Tennessee Denisea Gilliam, RN, BSN, Director of Emergency Services and Hospitalist Program, Ozarks Medical Center, West Plains, Missouri
3 FACILITATORS Availability of High Speed Cellular and WIFI Networks Ubiquitous Deployment of Electronic Medical Records Apple FaceTime Web Enabled Electronic Stethoscope NxStage Dialysis Machines for Acute Care
4 TELEMEDICINE: SIMPLICITY
5 LITTMANN TELESTETHOSCOPE
6
7 RENAL TELEMEDICINE In Patient Consult In-Hospital Acute Dialysis Outpatient Consults (Clinic and CKD)
8 EXPERIENCE AT A RURAL REGIONAL HOSPITAL General Information Inclusion Period (Months) 24 Number of Tele-Nephrologists 3 Total Admissions of Hospital (annualized from 2014) 11,374 Total In-Patient Bed Days of Hospital (annualized from 2014) 43,292 Percent of Admissions Requiring a Renal Consult 3.75% Percent of Inpatient Beds Days Requiring a Renal Consult 6.71% Percent of Inpatient Admissions ESRD 1.64% Total Consults 1978 Initial Consults 427 Follow-up Visits 1551
9 CHARACTERISTICS OF NON-ESRD PATIENTS REQUIRING DIALYSIS AKI Patients Needing Dialysis 15 CKD Progressing to ESRD Needing Dialysis 15 OD Requiring Dialysis 1 Total Non-ESRD Patients Requiring Dialysis 31 ARF/AKI Recovery From Dialysis Dependence ARF/AKI Regaining Renal Function 12 Percent of ARF/AKI Regaining Renal Function 80.0%
10 NUMBER OF INITIAL CONSULTS BY REASON Initial Consults by Reason ESRD Patient (at admission) 186 Acute Renal Failure 193 Drug Overdose 2 CKD 26 Electrolyte Disorders 20 Total Initial Consults 427
11 NUMBER OF DIALYSIS TREATMENTS BY PATIENT TYPE Number of Dialysis Treatments by Patient Type ESRD Dialysis ESRD Hemodialysis 405 ESRD Peritoneal Dialysis 70 Total ESRD Dialysis 475 Non-ESRD Hemodialysis CKD Progressing to ESRD Needing Dialysis 77 ARF/AKI Hemodialysis 45 Drug Overdose 1 Total Non-ESRD Hemodialysis 123 Total Number of Dialysis Treatments 598
12 DISPOSITION AT DISCHARGE Disposition at Discharge - ESRD Home/Rehab % Transferred to Tertiary % Hospice % Died in Hospital % Total ESRD % Disposition at Discharge - Non-ESRD Home/Rehab % Transferred to Tertiary % Hospice % Died in Hospital % Total Non-ESRD %
13 THE HOSPITAL S PERSPECTIVE The decision to add this service The implementation process The first year Subsequent years Denisea Gilliam, RN, BSN Director of Emergency Services and Hospitalist Program Ozarks Medical Center, West Plains, Missouri
14 CAN THIS WORK IN YOUR COMMUNITY?
15 DIALYSIS CLINICS IN MISSOURI
16 Current Situation Many Rural Hospitals Most Or All Patients With: ESRD AKI Electrolyte Disorders Dehydration And Pre-renal Azotemia Patients Are Transferred To Other Hospitals Delay of Treatment for the Patient (sometimes fatal) Hardship on Patient s Family Lost Revenue for the Local Hospital Reason: Shortage (Absence) Of Nephrologists For Acute Care Can t Perform Dialysis Without a Nephrologist s Orders and Oversight
17 ANALYSIS LOOK AT OUTMIGRATION DATA Determine Your Service Area How Far Must the Patient Travel to Receive In-Hospital Dialysis Service Area Might be Larger or Smaller Than Your Normal Service Area Depending on Availability Obtain Outmigration Data From Your PSA and SSA Looking for Patients Admitted Elsewhere with Primary or Co-Morbid Diagnoses of : ESRD (N18.6) CKD (Late Stage N18.4; N18.5) Acute Kidney Injury (AKI)
18 TYPICAL OPPORTUNITY BASED ON 10.5 DAYS PER YEAR OF HOSPITALIZATION AND 3.5 DAYS ALOS Radius (Minutes) ESRD Patients Days Admits Average e Daily Census Radius (Minutes) Lost Hospital ANNUAL NET REVENUE Lost Hospital ANNUAL EBITDA 30 $1,250,000 $500, $1,530,000 $612,000
19 FAVORABLE DRG S FOR DIALYSIS PATIENTS
20 TYPICAL ECONOMICS FOR HOSPITAL Fluid Overload AKA Congestive Heart Failure $9,000 Payment 3 Hospital Days 2 Dialysis Treatments 3 Telemedicine Visits Miscellaneous Imaging, EKG, Lab Incremental Profit - $4,000 (44% Margin) Community Acquired Pneumonia $9,500 Payment 5 Hospital Days 3 Dialysis Treatments 5 Telemedicine Visits Miscellaneous Imaging, EKG, Lab Incremental Profit - $3,000 (31% Margin)
21
22 SUMMARY Most ESRD Patients Can Be Managed With Telemedicine Most Non-ESRD Renal Patients Can Be Managed With Telemedicine Mortality Rate is Lower Than Predicted Telemedicine is an Effective Means of Providing Renal Consultation Telemedicine is an Effective Means of Monitoring Acute Dialysis Significantly reduce out-migration Create and maintain a new service line for the hospital
23 Deborah Tannenbaum SRS Telemedicine Sanderling Renal Services 511 Union Street, Suite 1800 Nashville, Tennessee (615)
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