Same-Day Discharge Is Ready for Prime Time in Selected Patients, Say Experts

November 12, 2012

LOS ANGELES — Operating under the paradoxical pretext that a hospital is not a safe place to be, a group of physicians presented data at the American Heart Association (AHA) 2012 Scientific Sessions on same-day discharge following PCI, suggesting that it could become more common in the US than current practice holds. Given the low complication rates and safety of patients from about six hours on post-PCI, experts believe that hospitals can safely set up a same-day-discharge program without increasing risks posed to patients.

Speaking during the plenary session, Dr Sunil Rao (Duke University Medical Center, Durham, NC) said the question is now whether "PCI has become so safe that we can successfully discharge selected patients home the same day." He noted that unless a patient has an acute coronary syndrome, PCI patients are all sent home within 24 hours. They are either classified as an "outpatient" and held for observation (less than 24 hours) or discharged the same day. "The major question is whether you send the patient home in 23 hours or do you send them home in six hours," said Rao. He added that the most risk for patients occurs in the early period, often within this critical first six hours.

"Is same-day discharge ready for prime time?" asked Rao. "I think it is among selected patients within the context of the program. The data do support this. Payers are now focused on length of stay and ready to levy fines. And for patients, a night at home is better than a night at the hospital."

Dr Rajiv Gulati (Mayo Clinic, Rochester, MN) highlighted the evolution of hospital stays in PCI, with patients previously having been admitted a day before, treated the following day, and sent home the next. Now the current situation in a vast majority of centers worldwide is a one-night stay, admitted the day of the procedure and sent home the next.

"On the plus side, most patients would like to go home the same day if possible," said Gulati. "I have no data to support that, there is none, but it seems intuitive, and talking to most patients they [say they] don't like staying in the hospital. Of course, there are overnight hospital safety issues to consider. Hospitals are not a safe place be. There are hospital-acquired infections, no patient sleeps well in a hospital, there is a risk of falls, and there is a well-publicized risk of medication errors while in the hospital."

The major question, however, is whether the evolution of PCI is going to continue, where same-day discharge expands to more and more patients, or, based on the law of diminishing returns, whether interventional medicine has peaked in terms of benefit and safety with a one-night hospital stay.

The SCAI Criteria and Low-Risk Patients

The Society of Cardiovascular Angiography and Interventions (SCAI) defines same-day PCI as an "outpatient" procedure, with the patient undergoing PCI and returning home to a nonmedical facility the same working day. In this setting, supervised medical care typically does not exceed 12 hours. A study published last year by Rao and colleagues showed that just 1.25% of 107 018 Medicare patients 65 years of age and older undergoing elective PCI were sent home the same day.

Importantly, though, the CathPCI Registry data also showed that same-day discharge was safe, with investigators reporting nearly equivalent rates of death and hospitalization at two and 30 days when compared with patients who stayed overnight. The registry included a majority of "straightforward" elective cases, but more than one-third of patients sent home the same day had a high-risk lesion, 16% underwent multivessel PCI, and 12% had a bifurcated lesion.

Speaking at the AHA meeting, Gulati said the pushback against same-day-discharge programs often comes from the caregivers. For example, family members might be concerned about taking care of an individual who recently underwent an invasive procedure, while nursing and cath-lab staff can also be resistant to change. As well, the interventional cardiologist might be concerned about complications that arise when the patient has been dismissed. There are practical concerns, too, as the hospital setting is a good place to implement education programs, such as those that deal with tobacco cessation and diet.

In terms of setting up a same-day-discharge program, Rao stressed the importance of patient education. "This is not a stent-and-send-home program," he said. "There has to be education of the patient, not only about the procedure, but you have to remember that for many of these patients this will be the first time learning they actually have coronary disease." At Duke University Medical Center, patients discharged the same day must have dual antiplatelet therapy in their hands before they leave. "We do not accept patients saying, I'll pick it up on my way home," said Rao, "because McDonald's is always more enticing than the pharmacy. We're worried that patients won't get their dual antiplatelet therapy after PCI."

Same Day Possible for Femoral and Radial PCI

There are approximately 20 studies that have addressed the issue of same-day discharge, including 12 that utilized the radial artery for PCI and eight that were conventional transfemoral PCIs, and there was no signal of harm in any of those analyses. However, he added that for physicians and hospitals looking to start a same-day program, it is important to define patient risk.

The current SCAI guidelines state that candidates for same-day discharge include those with stable angina who are asymptomatic. In addition, the patient should be without significant comorbidities, have normal renal and normal/near-normal left ventricular function, and be fully loaded with a thienopyridine and not glycoprotein IIb/IIIa inhibitors. Finally, SCAI recommends only patients undergoing successful, uncomplicated single-vessel PCI (with a <28-mm stent) who have family willing to consider early discharge should be candidates for same-day procedures.

The guidelines, said Gulati, are relatively conservative, but provide a good benchmark to identify low-risk patients who would be eligible for early discharge. The Mayo Clinic has adopted similar guidelines, with patients having the procedure in the morning and under observation for eight to 12 hours. After discharge, they return the next day for education and follow-up. It is believed that SCAI will be revisiting the same-day-discharge guidelines in 2013.

Discussing whether it is possible to push the boundaries and do more same-day-discharge PCI in high-risk patients, he cited data from a 2010 study by Dr Ian Gilchrist (Penn State College of Medicine, Hershey, PA). In that study of patients undergoing transradial PCI, same-day discharge was possible for many patients, including patients not considered candidates for same-day discharge by current criteria (only 15% of patients met the current SCAI criteria). The study was unique in that older patients, diabetic patients, and those who underwent complex procedures, as well as those who lived many miles from the treating hospital, were safely discharged the same day of the radial-access procedure.

For Rao, "same-day PCI does not mean radial PCI," he said. "There are reasonable data for using either approach, plus with closure devices, as long as you get ambulation."