Checklist for Same-Day Discharge PCI Stresses Buy-In, and a Plan

A growing body of evidence supporting safety and benefits has persuaded many hospitals to consider a switch to same-day discharge following PCI, but just how to get started may prove daunting. Now, a new expert consensus decision pathway released by the American College of Cardiology (ACC) aims to ease that transition.

“A lot of these same-day discharge protocols have been implemented in various hospitals around the country and around the world, but there hasn't been a single, summary document that really helps with implementation,” writing committee chair Sunil Rao, MD (Duke Clinical Research Institute, Durham, NC), told TCTMD. Rather than being a guideline summarizing the evidence—"the why”— this is more about “the how” of getting same-day discharge programs up and running, he said, while being adaptable to local practice and referral patterns. “This document is a really good distillation of what has worked in same-day discharge protocols for successful programs.”

The 2021 ACC Expert Consensus Decision Pathway on Same-Day Discharge After Percutaneous Coronary Intervention is published today in the Journal of the American College of Cardiology.

How, Not Why

The paper reviews the evidence in support of same-day discharge, then offers a checklist of considerations for any patient in whom same-day turnaround is being considered. These involve preprocedure and post-procedure factors that can be broken down according to clinical and social considerations. And these, stressed Rao, will be different for urban versus rural centers. Then, before discharge, another checklist can be used to verify plans for discharge medications, rehab, follow-up appointments, and patient education.

As the hospitals start filling up with COVID patients, we want to make sure that we're not ignoring patients who require PCI or revascularization, and at the same time, try to keep them safe by keeping them out of the hospital. Sunil Rao

Rao explained that when he’s worked with hospitals and teams in the past to implement same-day discharge programs, he’s advocated a “three Ps” approach: patient, procedure, and program. First, patients must be amenable and suitable for same-day discharge, which means also having the needed support at home. Then the procedure itself must be appropriate and must go successfully, without complications, access-site concerns, or the need for protracted IV antithrombotics, for example. Finally, any decisions must be taken within the context of an organized program, said Rao, which means getting buy-in from all caregivers involved in pre- and post-care, from practice providers to nurses, pharmacists, and registration staff.

Indeed, buy-in from hospital and facility administration is emphasized in the document, with the suggestion that physician champions take up the charge and meet with staff administrators to present the data and checklist. Getting post-procedure staff on board is particularly important, since prolonged observation has long been the “culture” following PCI, particularly following femoral procedures “and there may be a higher level of discomfort in sending those patients home the same day,” Rao said.

The document also makes a point of noting that same-day discharge is not synonymous with radial procedures, although the two have often been championed together. Rao, a longtime advocate of radial access, points out that much of the published data on same-day discharge actually involves patients who underwent femoral procedures. “So, while radial can certainly facilitate a faster recovery, we did not want to give the impression that in order to do same-day discharge, you have to do transradial,” he said. “You can certainly do it with transfemoral: the key is to make sure that the access site is stable before the patient goes home.”

One concern that’s been raised about same-day discharge is that it shortens the window of opportunity for physicians and nurses to hammer home messaging around secondary prevention and dual antiplatelet therapy—a point also emphasized in the document. Rao, however, points out that an overnight stay does not necessarily translate into better uptake of medical therapy post-PCI; a plan for clearly communicating the drug regimen and its benefits to patients is essential, regardless of how long they spend in the hospital.   

“We do have to make a concerted effort to do that for a variety of reasons. Number one, for many patients, this is their first manifestation of coronary disease and they have to be educated about the fact that secondary prevention is probably the most important thing they can do.” The second reason, Rao continued, is more practical. “For many of us that are participating in [quality improvement] registries, we have to be really attentive to the fact that patients need to be on all of the secondary prevention medications and be referred to cardiac rehabilitation, not only for their benefit, but also to make sure that we're meeting our quality metrics.”

Fortuitous Timing

According to Rao, the document has been in the works for several years, but the timing is particularly “fortuitous,” given the impact of COVID-19 on hospital bed shortages and the cancellation of elective cardiac procedures in many regions. The ability to have patients undergo PCI procedures and head home the same day has clear advantages amid surging virus cases, overflowing ICUs, and procedure cancellations.

“Obviously, everyone is worried about the pandemic and keeping everyone safe, but at the same time we are trying to conduct business as much as we can, because patients who have cardiovascular disease can be very stable one second and then be unstable the next. So, we can't ignore our day-to-day responsibilities, and I think in that context, we hope that people will find this paper very useful. As the hospitals start filling up with COVID patients, we want to make sure that we're not ignoring patients who require PCI or revascularization, and at the same time, try to keep them safe by keeping them out of the hospital.”