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If Only the Doctor Will Let Me Go Home: Same Day Discharge after PCI
Cardiovascular Revascularization Medicine 18 (2017) 231–232
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Editorial
If Only the Doctor Will Let Me Go Home: Same Day Discharge after PCI
Coronary revascularization and home by dinner. Thirty years ago, this would have been dreaming. Admission one day with cardiac catheterization the next was the norm. Several days to consider whether PTCA could be done with surgical backup, then a day or two extra after the PTCA to make sure the sheaths came out of the groin without too much blood loss. The intervention left the coronary unstable without a stent, and the groin was unstable without reliable closure. Reimbursement also encouraged hospitalization while everyone was waiting. Fast forward to today, and many things have changed. Stents have made the coronary artery stable after the intervention, and radial access has obviated worries over the femoral artery’s stability after hemostasis. Patients are ready for discharge, but physicians and the healthcare system still can’t seem to discharge on the same day. Same-day discharge is nothing new. Kiemeneij, in the 1990’s, released early Palmaz-Schatz stent patients home the same day if they had been pre-loaded with Coumadin as an outpatient before the common use of antiplatelet therapy [1]. We were discharging elective patients home the same day in the US in the late 1990’s after short courses of GP IIb/IIIa agents [2]. Data clearly shows no measurable harm as far as outcomes [3], and early discharge obviates the risk of hospitalization [4]. Today many institutions don’t send anyone home the same day, while others send most of their elective procedures home the same day. A multitude of relatively small studies, usually observational in nature, have revealed their experience with same day discharge. These papers typically discussed a variety of characteristics to define an appropriate patient for same day discharge, but consensus is consistent with only 3 criteria: 1) Uncomplicated procedure with an excellent, stented result, 2) No complications during hemostasis and 4-6 hours of observation, and 3) Social support readily available immediately after discharge with access to healthcare. The strongest predictor of same day discharge that is not related to the patient is the physician doing the procedure; some physicians almost always do same-day discharge while other physicians never send patients home the same day. Once the patient has undergone a relatively uneventful PCI, preprocedural PCI risk-models are no longer relevant since the dominate short-term risk of the procedure has passed, and chronic risk factors for long-term outcome dominate the future risk. Stable patients with stable coronary arteries and stable access arteries do well in the shortterm whether relaxing at home or being kept overnight in the hospital. If they walked into the hospital in the morning without the need for acute hospitalization, the minor trauma of the PCI procedure should not prevent discharge by sunset. Dr. Koutouzis and colleagues, in this issue [5], published their institutions experience with same day discharge. They noted a successful procedure, proximity to care after hours, and a transradial
http://dx.doi.org/10.1016/j.carrev.2017.05.017 1553-8389/© 2017 Published by Elsevier Inc.
approach were positive predictors for same day discharge. Likewise, unstable clinical syndromes and procedures requiring increased volumes of contrast were associated with less likelihood of same day discharge. Consistent with physician comfort versus actual patient characteristics driving decisions for same day discharge, they found their same day discharge rate climbed from 9.3% in 2013 to 34.5% in 2015. These results are consistent with the observation that stable patients with stable arteries after PCI can go home if they have appropriate social support at home. That should be the vast majority of modern, elective PCI procedures. If most are not being discharged the same day, it is more costly, without added benefit, and represents healthcare waste [6]. The variability in same day discharge practices across operators with no clear association with differences in outcome speaks strongly in support for education in this matter and relevant guidelines. Professional guidelines from 2009 do not accurately reflect the procedural safety introduced by transradial access [7] and the experience across many patient subsets that demonstrate a robust safety profile to modern PCI techniques. Shifts in medical care that now result in a stable coronary artery and stable access sites after routine PCI procedures need to be reflected in de-escalation of medical care and further shift of these patients to same day status to reap the maximum benefit from progress.
Ian C. Gilchrist, MD Professor of Medicine, Pennsylvania State University, College of Medicine, Heart & Vascular Institute, Hershey, PA, 717-531-5888 E-mail address: [email protected]
References [1] Kiemeneij F, Laarman GJ, Slagboom T, van der Wieken R. J Am Coll Cardiol 1997; 29(2):323–7. [2] Gilchrist IC, Nickolaus MJ, Momplaisir T. Same-Day, Transradial, Outpatient Stenting With A 6-Hour Course Of Glycoprotein IIb/IIIa Receptor Blockade: A Feasibility Study. Catheter Cardiovasc Interv 2002;56:10–3. [3] Abdelaal E, Rao SV, Gilchrist IC, Bernat I, Shroff A, Caputo R, et al. Same-Day Discharge Compared to Overnight Hospitalization After Uncomplicated Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. J Am Coll Cardiol Intv 2013; 6(2):99–112. [4] Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med Care 2011;49(12):1068–75.
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[5] Koutouzis M, Agelaki M, Maniotis C, et al. Predictors of same day discharge after percutaneous coronary interventions. Cardiovasc Revasc Med Jan 8 2017;18: 241–4. [6] Amin AP, Patterson M, House JA. Costs Associated With Access Site and Same-Day Discharge Among Medicare Beneficiaries Undergoing Percutaneous Coronary Inter-
vention: An Evaluation of the Current Percutaneous Coronary Intervention Care Pathways in the United States. JACC Cardiovasc Interv 2017 Feb 27;10(4):342–51. [7] Gilchrist IC, Rhodes D, Zimmerman HE. A Single Center Experience with Same-Day Transradial-PCI Patients: A Contrast With Published Guidelines. Catheter Cardiovasc Interv 2012;79(4):583–7.
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Editorial
If Only the Doctor Will Let Me Go Home: Same Day Discharge after PCI
Coronary revascularization and home by dinner. Thirty years ago, this would have been dreaming. Admission one day with cardiac catheterization the next was the norm. Several days to consider whether PTCA could be done with surgical backup, then a day or two extra after the PTCA to make sure the sheaths came out of the groin without too much blood loss. The intervention left the coronary unstable without a stent, and the groin was unstable without reliable closure. Reimbursement also encouraged hospitalization while everyone was waiting. Fast forward to today, and many things have changed. Stents have made the coronary artery stable after the intervention, and radial access has obviated worries over the femoral artery’s stability after hemostasis. Patients are ready for discharge, but physicians and the healthcare system still can’t seem to discharge on the same day. Same-day discharge is nothing new. Kiemeneij, in the 1990’s, released early Palmaz-Schatz stent patients home the same day if they had been pre-loaded with Coumadin as an outpatient before the common use of antiplatelet therapy [1]. We were discharging elective patients home the same day in the US in the late 1990’s after short courses of GP IIb/IIIa agents [2]. Data clearly shows no measurable harm as far as outcomes [3], and early discharge obviates the risk of hospitalization [4]. Today many institutions don’t send anyone home the same day, while others send most of their elective procedures home the same day. A multitude of relatively small studies, usually observational in nature, have revealed their experience with same day discharge. These papers typically discussed a variety of characteristics to define an appropriate patient for same day discharge, but consensus is consistent with only 3 criteria: 1) Uncomplicated procedure with an excellent, stented result, 2) No complications during hemostasis and 4-6 hours of observation, and 3) Social support readily available immediately after discharge with access to healthcare. The strongest predictor of same day discharge that is not related to the patient is the physician doing the procedure; some physicians almost always do same-day discharge while other physicians never send patients home the same day. Once the patient has undergone a relatively uneventful PCI, preprocedural PCI risk-models are no longer relevant since the dominate short-term risk of the procedure has passed, and chronic risk factors for long-term outcome dominate the future risk. Stable patients with stable coronary arteries and stable access arteries do well in the shortterm whether relaxing at home or being kept overnight in the hospital. If they walked into the hospital in the morning without the need for acute hospitalization, the minor trauma of the PCI procedure should not prevent discharge by sunset. Dr. Koutouzis and colleagues, in this issue [5], published their institutions experience with same day discharge. They noted a successful procedure, proximity to care after hours, and a transradial
http://dx.doi.org/10.1016/j.carrev.2017.05.017 1553-8389/© 2017 Published by Elsevier Inc.
approach were positive predictors for same day discharge. Likewise, unstable clinical syndromes and procedures requiring increased volumes of contrast were associated with less likelihood of same day discharge. Consistent with physician comfort versus actual patient characteristics driving decisions for same day discharge, they found their same day discharge rate climbed from 9.3% in 2013 to 34.5% in 2015. These results are consistent with the observation that stable patients with stable arteries after PCI can go home if they have appropriate social support at home. That should be the vast majority of modern, elective PCI procedures. If most are not being discharged the same day, it is more costly, without added benefit, and represents healthcare waste [6]. The variability in same day discharge practices across operators with no clear association with differences in outcome speaks strongly in support for education in this matter and relevant guidelines. Professional guidelines from 2009 do not accurately reflect the procedural safety introduced by transradial access [7] and the experience across many patient subsets that demonstrate a robust safety profile to modern PCI techniques. Shifts in medical care that now result in a stable coronary artery and stable access sites after routine PCI procedures need to be reflected in de-escalation of medical care and further shift of these patients to same day status to reap the maximum benefit from progress.
Ian C. Gilchrist, MD Professor of Medicine, Pennsylvania State University, College of Medicine, Heart & Vascular Institute, Hershey, PA, 717-531-5888 E-mail address: [email protected]
References [1] Kiemeneij F, Laarman GJ, Slagboom T, van der Wieken R. J Am Coll Cardiol 1997; 29(2):323–7. [2] Gilchrist IC, Nickolaus MJ, Momplaisir T. Same-Day, Transradial, Outpatient Stenting With A 6-Hour Course Of Glycoprotein IIb/IIIa Receptor Blockade: A Feasibility Study. Catheter Cardiovasc Interv 2002;56:10–3. [3] Abdelaal E, Rao SV, Gilchrist IC, Bernat I, Shroff A, Caputo R, et al. Same-Day Discharge Compared to Overnight Hospitalization After Uncomplicated Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. J Am Coll Cardiol Intv 2013; 6(2):99–112. [4] Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med Care 2011;49(12):1068–75.
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[5] Koutouzis M, Agelaki M, Maniotis C, et al. Predictors of same day discharge after percutaneous coronary interventions. Cardiovasc Revasc Med Jan 8 2017;18: 241–4. [6] Amin AP, Patterson M, House JA. Costs Associated With Access Site and Same-Day Discharge Among Medicare Beneficiaries Undergoing Percutaneous Coronary Inter-
vention: An Evaluation of the Current Percutaneous Coronary Intervention Care Pathways in the United States. JACC Cardiovasc Interv 2017 Feb 27;10(4):342–51. [7] Gilchrist IC, Rhodes D, Zimmerman HE. A Single Center Experience with Same-Day Transradial-PCI Patients: A Contrast With Published Guidelines. Catheter Cardiovasc Interv 2012;79(4):583–7.