Same-Day Discharge After PCI

Percutaneous coronary intervention (PCI) has traditionally been an inpatient procedure, requiring at least an overnight observation in the hospital to monitor for access site complications and post-procedural ischemic events. The advanced technology and pharmacotherapy have improved the success rate and safety of this procedure over the last three decades. The adjunct pharmacotherapy, improved stent designs, smaller sheath size, closure devices, and transradial approach are among the many factors that have made PCI procedures safer and more successful. The model of post-PCI care in Europe and Canada has shifted towards same-day discharge (SDD), while overnight observation is still the common practice in the United States.

The Society of Cardiovascular Angiography and Interventions (SCAI) published the consensus document on the required length of stay after elective PCI in 2009, with a conservative approach towards same-day discharge. According to this consensus document, same-day discharge was only recommended for patients with no comorbidities, normal renal function, normal left ventricular ejection fraction (LVEF), single-vessel PCI and immediate post-procedure access site stabilization.¹  

Some of the earlier studies to determine the feasibility of SDD showed that the majority of post-procedural complications occur in the first 6 hours after an elective PCI.² Randomized clinical trials have shown no difference in 30-day outcome between SDD and overnight admissions using both transfemoral and transradial approaches for elective PCI^3-6, although patients in the transradial trials tend to be a higher risk cohort.  Patients with pre-existing peripheral vascular disease, chronic anticoagulation, repeated use of the femoral artery, or larger sheath size were excluded from the trials using the transfemoral approach.^4,5 Some of the transfemoral trials required a follow-up visit the day after discharge for groin access site examination.⁷ While same-day discharge has been feasible in transfemoral PCIs after an uncomplicated PCI, the concern for vascular complications seems to be the source of inertia behind the move to discharge the patients the same day. A transradial approach can clearly eliminate the concerns related to hemostasis and vascular complications, and will facilitate the adoption of SDD.

In a recent analysis of almost 280,000 PCIs in the National Cardiovascular Data Registry by Amin et al, only 5.3% of patients eligible for SDD were discharged home the same day.⁸ In this cohort, 9% of the PCIs were performed using a transradial approach and only one out of four patients in the transradial group was discharged home the same day. The reasons for keeping patients in the hospital after a successful transradial PCI remain unclear, and deserve discussion and analysis. This study also suggested that shifting the practice pattern to transradial approach and SDD will result in significant cost savings for the hospital.8 Several studies have suggested that SDD is also the patients’ preference.⁹

In patients who had a successful PCI with optimal result, a transradial approach and same-day discharge is an option that is safer and more pleasant for the patients, and one that saves the healthcare system a great deal of money. It is inevitable that with the rise of transradial PCI volume in the U.S., there will be a growing number of hospitals and physicians that will adopt SDD for patients after successful PCI with optimal results.  

The cardiac catheterization lab at George Washington University began the transition to a transradial approach in 2010. The majority of cases in our catheterization lab are performed by three radialists. As the percentage of transradial PCIs increased over time, the algorithm for post-PCI care in our institution was modified. The nursing needs for patients after transradial PCI in a hospital room on the telemetry floor were noted to be minimal, and the need for overnight observation was no longer justified for patients who were out of bed and walking after a couple of hours. The next, natural step was to eliminate the need for utilization of a hospital bed. Instead, we invested in creating a radial lounge with 5 recliners, staffed by one nurse and one technologist to provide post-PCI care for patients who had successful transradial PCI. The decision to utilize a hospital bed vs a radial lounge is made by the physician, and is dictated by patient-specific and procedure-specific factors. Patients with successful PCI, with no post-procedure chest pain, and no angiographic evidence of side branch loss or distal embolization, adequate radial puncture site hemostasis, no evidence of heart failure, and no complications related to conscious sedation, will be candidates for recovery in the radial lounge and will be discharged in 3 to 4 hours. Prescriptions are sent electronically to the nearest pharmacy, and a follow-up appointment is made before discharge. In the last three years, a transradial approach has been used in 92% of our elective PCIs, and 78% of these patients have been discharged home the same day. With the increasing number of transradial PCIs in the U.S., the evolution of post-PCI care and the shift towards same-day discharge is inevitable, supported by data and cost effectiveness. 

References

1. Chambers CE, Dehmer GJ, Cox DA, et al; Society for Cardiovascular Angiography and Interventions; endorsed by the American College of Cardiology Foundation. Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2009; 73(7): 847-858.
2. Jabara R, Gadesam R, Pendyala L, et al. Ambulatory discharge after transradial coronary intervention: preliminary US single-center experience (Same-Day TransRadial Intervention and Discharge Evaluation, the STRIDE Study). Am Heart J. 2008; 156(6): 1141-1146.
3. Bertrand OF, De Larochellière  R, Rodés-Cabau J, et al; Early Discharge After Transradial Stenting of Coronary Arteries Study Investigators. A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation. 2006; 114(24): 2636-2643.
4. Heyde GS, Koch KT, de Winter RJ, et al. Randomized trial comparing same-day discharge with overnight hospital stay after percutaneous coronary intervention: results of the Elective PCI in Outpatient Study (EPOS). Circulation. 2007; 115(17): 2299-2306.
5. Kim M, Muntner P, Sharma S, et al. Assessing patient-reported outcomes and preferences for same-day discharge after percutaneous coronary intervention: results from a pilot randomized, controlled trial. Circ Cardiovasc Qual Outcomes. 2013; 6(2): 186-192.
6. Shroff A, Kupfer J, Gilchrist IC, et al. Same-day discharge after percutaneous coronary intervention: current perspectives and strategies for implementation. JAMA Cardiol. 2016 May1; 1(2): 216-223.
7. Dalby M, Davies J, Rakhit R, et al; Feasibility and safety of day-case transfemoral coronary stenting. Catheter Cardiovasc Interv. 2003 Sep; 60(1): 18-24.
8. Amin AP, Patterson M, House JA, et al. Costs associated with access site and same-day discharge among Medicare beneficiaries undergoing percutaneous coronary intervention: an evaluation of the current percutaneous coronary intervention care pathways in the United States. JACC Cardiovasc Interv. 2017 Feb 27; 10(4): 342-351. 
9. Abdelaal E, Rao SV, Gilchrist IC, et al. Same-day discharge compared with overnight hospitalization after uncomplicated percutaneous coronary intervention: a systematic review and meta-analysis. JACC Cardiovasc Interv. 2013 Feb; 6(2): 99-112.