Among Medicare recipients, PCI is one of the most commonly performed cardiac procedures in the United States, with more than 1 million procedures being performed each year. Research has shown that the risks associated with PCI are highest within the first 24 to 48 hours after the procedure. Fortunately, both short- and long-term outcomes after PCI have improved substantially over the years because of the evolution of devices, technology, and pharmacotherapy.
Despite recent advances, patients are usually observed overnight in the hospital after elective PCI to monitor for complications, sometimes in short-stay units and other times on traditional nursing floors as inpatients. This practice occurs even though some studies suggest that these patients can be discharged home safely on the same day of PCI without the need for overnight observation. The potential benefits of same-day discharge of patients include the elimination of an overnight hospital stay for patients, increased bed availability for the hospital, and cost savings.
New Data on Discharge of PCI Patients
Little is known about how often patients are discharged home the same day as their PCI. To shed light on the matter, my colleagues and I conducted a study using data from more than 107,000 patients aged 65 and older from the National Cardiovascular Data Registry CathPCI Registry and linked it with CMS claims data. Patients were either discharged the same day as their procedure or 24 or more hours after it. The investigation, published in the October 5, 2011 JAMA, examined trends in death or rehospitalization occurring within 2 days and by 30 days after PCI.
“Same-day discharge was rarely implemented in low-risk Medicare patients undergoing elective PCI.”
Our analysis revealed that same-day discharge was rarely implemented in low-risk Medicare patients undergoing elective PCI. The prevalence of same-day discharge was 1.25% among study participants. Patient characteristics were similar between those who had a same-day discharge and those with an overnight stay. However, same-day discharge patients underwent shorter procedures with less multivessel intervention than overnight stay patients. There were also no significant differences in the rates of death or rehospitalization at 2 days or at 30 days. For patients who experienced adverse outcomes, the median time to death or rehospitalization was not statistically different between the two groups assessed in the analysis. Bleeding rates were also extremely low—about 1%—for both groups.
Creating a PCI Patient Release Program
To adopt the practice of discharging elective PCI patients within 24 hours, it’s important that a program be in place to optimize outcomes. It requires a systematic effort that involves a teamwork approach. The patient must be at very low risk, the procedure must be deemed a success, and nursing staff and personnel must ensure that patients are properly educated and discharged with the medications they need. Patients should also live in close proximity to the hospital and have a support system at home in which caregivers will stay with them so that physicians or healthcare providers can be contacted if something unexpected happens.
As physicians, we need to rethink discharging practices with elective PCI. Studies have shown that same-day discharges in very low-risk PCI patients will not impact hospital revenue positively or negatively. Our focus should be on the hospital beds that these patients occupy and the risks that they’re exposed to when they unnecessarily have an overnight hospitalization. Having a strong program in place can optimize outcomes for elective PCI recipients.
Readings & Resources (click to view)
Rao SV, Kaltenbach LA, Weintraub, WS, et al. Prevalence and outcomes of same-day discharge after elective percutaneous coronary intervention among older patients. JAMA. 2011;306:1461-1467. Available at: http://jama.ama-assn.org/content/306/13/1461.full.
Rao SV,Ohman EM. Anticoagulant therapy for percutaneous coronary intervention. Circ Cardiovasc Interv. 2010;3:80-88.
Singh M, Rihal CS, Gersh BJ, et al. Twenty-fiveyear trends in in-hospital and long-term outcome after percutaneous coronary intervention: a single-institution experience. Circulation. 2007;115:2835-2841.
Roe MT, Messenger JC, Weintraub WS, et al. Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. J Am Coll Cardiol. 2010;56:254-263.
Ormiston JA, Shaw BL, Panther MJ, et al. Percutaneous coronary intervention with bivalirudin anticoagulation, immediate sheath removal, and early ambulation: a feasibility study with implications for day-stay procedures. Catheter Cardiovasc Interv. 2002; 55:289-293.
Ziakas AA, Klinke BP, Mildenberger CR, et al. Safety of same-day-discharge radial percutaneous coronary intervention: a retrospective study. Am Heart J. 2003;146:699-704.