Same-Day Discharge After PCI Is Safe, With Benefits for Patients and Hospitals: Review


Take Home. Same-Day Discharge After PCI Is Safe, With Benefits for Patients and Hospitals: ReviewSame-day discharge after elective PCI—which has been practiced in certain centers for a decade or more now—can be safely offered to select patients who undergo uncomplicated procedures and who have social support in place, according to a review of the literature.

“Same-day discharge following elective angioplasty is safe, is appropriate, and is an option for many patients,” lead author Adhir Shroff, MD (University of Illinois at Chicago), told TCTMD. “Healthcare providers [and] medical centers in the United States ought to develop a program for their patients.”

For patients eligible for same-day discharge—perhaps up to 75% of low-risk patients undergoing elective PCI—an observation period of 4 to 6 hours before going home seems to be adequate based on existing research, he and colleagues note in their paper published online March 30, 2016, ahead of print in JAMA Cardiology.

“Greater adoption of [same-day discharge] programs after PCI has the potential to improve patient satisfaction, increase bed availability, and reduce hospital costs without increasing adverse patient outcomes,” they write.

Commenting for TCTMD, Samin Sharma, MD (Mount Sinai Hospital, New York, NY), said the issue of same-day discharge has been put to rest, with releasing patients after a recovery period of 4 to 6 hours becoming the default approach. He noted that slightly more than half of elective PCI patients at his center (52%) are discharged on the same day as the procedure.

It is important to approach every patient undergoing elective PCI as a potential candidate for same-day discharge, he said, and then use a rigorous protocol to identify who requires additional attention and should be admitted—those who are allergic to contrast, have high serum creatinine, or have heart failure, for example. Also, patients who have complications during PCI or who develop symptoms during the recovery period should not be discharged on the same day, he said.

Although not a new concept, same-day discharge is a departure from the historical norm of requiring an inpatient stay of at least 24 hours after PCI to monitor for acute ischemic events. Improvements in technology, techniques, and adjunctive pharmacology over the years have, however, created an environment in which same-day discharge might make more sense.

But there is still little direction from the major societies to help guide the use of same-day discharge, Shroff said. The Society for Cardiovascular Angiography and Interventions (SCAI) released a consensus statement on length of stay after PCI in 2009, but that was subject to certain limitations, he and his coauthors say.

Thus, the purpose of the current review is to provide physicians and medical centers up-to-date information about the evidence available to support same-day discharge and how the practice is being implemented, Shroff said.

Benefits for Patients, Hospitals

The review revealed that same-day discharge is not associated with increases in adverse events like bleeding, repeat coronary procedures, death, or rehospitalization. Most complications have been shown to occur within 6 hours of PCI, with an “extremely low” risk beyond that. The safety of same-day discharge did not seem to be influenced by the choice of vascular access site.

Considering the comparable clinical outcomes in patients discharged on the same day or admitted overnight, the benefits to patients manifest as an increase in comfort from being able to return home earlier and a lower risk of nosocomial complications such as infections, accidents, or drug errors, Shroff said.

In terms of economic impact, same-day discharge has been consistently associated with lower healthcare systems costs related to avoiding an overnight stay.

Shroff and colleagues note that is has been estimated that the US healthcare system could save $200 to $500 million each year if half of patients undergoing PCI are released the day of the procedure.

“While these savings may change as the reimbursement landscape continues to evolve, it is clear that [same-day discharge] after uncomplicated PCI has the potential to use fewer hospital resources and decrease the intensity of care without compromising safety,” they write.

Implementing Same-Day Discharge

According to the authors, there are five domains central to a successful same-day discharge program:

  • Accurate assessment of suitability for same-day discharge, taking into account several factors, including frailty, health literacy, and the presence of social support
  • Excellent procedural outcomes that include successful PCI, no compromise of a side branch at least 2 mm in diameter, and no postprocedural chest pain
  • Rapid and reliable stabilization of vascular access site
  • Reliable provision of dual antiplatelet therapy
  • Postprocedural patient education about common complications and what to do about them

Shroff and colleagues say that successful development of a same-day discharge program should involve several groups, including physicians, care extenders, nurses, hospital administrators, and recovery unit staff.

It is important to formalize the process for determining which patients can be sent home early and which need to be admitted for longer observation, Shroff said.

Although some documents, including the 2009 SCAI statement, have tried to establish strict criteria based on age and comorbidities about which patients should not be eligible for same-day discharge, Shroff said the focus should be on whether the procedure is completed successfully without complications and whether the patient has an uneventful recovery period.

Patients undergoing complex interventions are generally discouraged from leaving on the same day, he said.

“We really want to advocate a very conservative approach. It should start off in a selected population of patients that have a very low risk of having events,” he said, adding that the same-day discharge could be offered to other groups of patients as comfort level increases at a medical center.

What’s Holding Same-Day Discharge Back?

A potential barrier to greater use of same-day discharge is the fact that most patients undergoing elective PCI are still kept overnight, and there is concern that legal issues could arise from deviating from standard practice.

“Clear communications with the patient and family about the potential risks after discharge and a plan on how to react to an unexpected event, including a safety net, are important measures for both patient safety and the prevention of legal liability,” Shroff and colleagues say.

Sharma said the medicolegal concern about same-day discharge used to be greater, “but now enough has been published in the literature that it’s completely safe, so more and more centers are adopting this policy now.”

A strong recommendation for same-day discharge from the American College of Cardiology also would help to overcome some of the inertia on the part of physicians and medical centers, he added.

Shroff cited other hypothetical concerns: that reimbursement will continue to decrease for PCI if same-day discharge becomes more commonplace and that patients will not take their condition as seriously if they do not view PCI as a major procedure requiring prolonged time in the hospital.

But Shroff dismissed those, saying, “I don’t think that those hypothetical concerns should really keep us from providing care that probably is beneficial for patients.”


Source:
  • Shroff A, Kupfer J, Gilchrist IC, et al. Same-day discharge after percutaneous coronary intervention: current perspectives and strategies for implementation. JAMA Cardiol. 2016;Epub ahead of print.

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Disclosures
  • Shroff and Sharma report no relevant conflicts of interest.

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