Same-Day Discharge in PCI: 'Next Step' in Evolution of PCI

Patrice Wendling

April 20, 2016

CHICAGO, IL — Same-day discharge is safe in selected PCI patients but remains underutilized, according to a clinical review of the evidence[1].

"There are very successful programs that are doing 4 hours of observation, some 6; our group just happens to be a little on the conservative side at 8 hours; I think somewhere in there, there's a sweet spot," lead author Dr Adhir Shroff (University of Illinois at Chicago) told heartwire from Medscape.

The investigators assembled data from five randomized clinical trials comparing same-day discharge (SDD) with overnight observation after PCI as well as observational studies, meta-analyses guidelines, and consensus statements published from 1995 to 2015.

The review found that the likelihood of complication occurring beyond 6 hours after PCI is "extremely low" and concludes that a postprocedural observation period of 4 to 6 hours is reasonable for most low-risk PCI patients.

Overall, "there are considerable peer-reviewed published data showing that SDD PCI in appropriately selected patients is safe" and that there is no increase in adverse events, according to the paper, published online March 30, 2016 in the JAMA Cardiology. "Same-day discharge after low-risk cases is the next step in the evolution of PCI," the authors conclude.

While SDD PCI is being used in pockets across the US, more than half of elective PCI involves up to 24 hours of observation, Shroff said. Many clinicians are looking for more support in the published literature to back up their practice, while for others it's a knowledge gap or inertia with respect to changing practices.

"In every modern cath-lab practice or interventional practice there are opportunities and certain patients who would be eligible for same-day discharge; what it requires is a change in the culture," he said.

Overarching Principles

The authors detail five essential domains needed for successful implementation of SDD-PCI:

  • Accurate assessment of suitability for SDD.

  • Excellent procedural outcomes.

  • Rapid and reliable stabilization of the vascular-access site, allowing for early and safe ambulation.

  • Reliable provision of dual antiplatelet therapy.

  • Postprocedural patient education, routine early follow-up, and tracking of outcomes.

Shroff said they strove not to be overly prescriptive in their recommendations because the details of each program need to be tailored to the individual center or group. In contrast, early documents like the 2009 Society for Cardiovascular Angiography and Interventions consensus statement on appropriate use of same-day and outpatient status in the catheterization lab contain such conservative recommendations that they'd exclude most patients now undergoing PCI, including those with any chronic comorbidity or older than 70 years.

"There are some 75-year-olds who are incredibly healthy and very competent to take care of themselves, so why shouldn't we let those people go home?" Shroff asks. "We wanted to avoid arbitrary cutoffs whenever possible and focus on uncomplicated procedures with uneventful observation periods."

That said, he stressed that each PCI program should have a standardized SDD protocol rather than individual physician protocols and must have established follow-up protocols to ensure patient safety.

"Previously, patients were receiving all this education about their procedure and follow-up care in a 24-hour period, and now we're saying this needs to happen in about an 8-hour period, so we really have to be smart about this and have tools to assist us," he said. To that end, his university is now piloting an iPad app to help guide patients through the process.

For clinicians still not convinced, the paper details the potential economic savings with SDD, estimated to be between $200 million and $500 million per year if half of the patients undergoing PCI in the US were discharged the same day. In 2015, Medicare reimbursements for an outpatient PCI with one or two drug-eluting stents were $9624 and $14,841, respectively.

The authors reported no relevant financial disclosures.

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