Should Your Program Be Considering Same-Day PCI Discharge From a Dedicated Lounge?

This month, we are joined by John Wang, MD, MSc, FACC, FSCAI, Chief of the Cardiac Catheterization Laboratory, Medstar Union Memorial Hospital, Baltimore, Maryland, and Cheryl Lunnen, Regional Vice President, MedStar Heart & Vascular Institute. This is a busy, dynamic program that has been utilizing transradial access with increasing regularity for the past eight years, which ultimately led to their decision to incorporate a same-day discharge lounge into their care pathway. I think you will find their story compelling and insightful for any program considering a same-day lounge.  — Gary Clifton, Vice President, Terumo Business Edge

Dr. Wang, you and your service line partner, Cheryl Lunnen, went to great lengths to implement a same-day discharge (SDD) program that utilizes a dedicated radial lounge. What was the deciding factors that went into the need or desire to create a radial lounge as part of that solution?

John Wang, MD: A radial lounge is not something you start with, but is the final component of a successful transradial program. It is not a “field of dreams” where you build it and they will come; you need a robust radial program with enough volume to fill the lounge. Over the past eight years, we have steadily grown our radial utilization where we now have achieved 90% for diagnostic cases and over 80% for interventions, with a total annual percutaneous coronary intervention (PCI) volume of approximately 1100 cases. My advice to hospitals who may be considering a radial lounge is to critically examine the cath lab’s total radial volume, not just that of a few physicians. It is important to look at the cath lab’s National Cardiovascular Data Registry (NCDR) data to get an accurate accounting of radial access utilization for all cases. 

Cheryl Lunnen, Regional Vice President, MedStar Heart & Vascular Institute: It is important to differentiate the radial lounge from the radial approach. We all felt it was necessary to develop enough volume whereby you could segregate out a population that was going to be able to have a different experience and go through a same-day discharge program in an innovative way with a high patient experience. All the physicians were encouraged to master the radial technique. But I agree with Dr. Wang — it was all about having the volume to justify the creation and use of a radial lounge that could facilitate same-day discharge.

Can you provide some key highlights of your same-day discharge (SDD) criteria and use of the radial lounge? 

Dr. Wang: For our program, transradial access was always a key component of any patient being discharged the same day. With the improved safety of present generation drug-eluting stents (DES) and antiplatelet agents, we became less concerned about acute stent thrombosis and the real fear was more centered on vascular complications from groin access. Even with the use of vascular closure devices, physicians have all experienced, at some point, a patient with late closure failure in the middle of the night. We have tried to eliminate arbitrary cutoffs for SDD. An example is the acute coronary syndrome (ACS) patient. Not all non ST elevation myocardial infarctions (NSTEMI) are the same. If a patient came in on Friday with a troponin of 1, and by Monday is stable with normal levels and you cath them, it is still considered a NSTEMI, but I am likely to send this patient home the same day. Not one size fits all and we try and employ some common sense in each case. Obviously, patients that present with renal failure with high creatinine levels or STEMIs are going to spend at least one night. In contrast, elderly patients, proximal left anterior descending (LAD) lesions, protected left main stenting, and complex bifurcations are considered on a case-by-case basis. In our program, the interventionalist, upon the conclusion of the procedure, makes the decision as to whether or not the patient is going to the radial lounge, thus everyone on the team knows what the plan is in order for that patient to go home the same day. All same-day percutaneous coronary intervention (PCI) discharge patients will have their thienopyridine medication in hand and we will make sure that someone can stay with them that evening. 

Cheryl: It is also operational. You can’t wait till 5 hours post procedure to be making the decision to discharge same day. You have missed the opportunity to educate, conduct the routine things we would have done in an overnight stay, and now you are trying to rush them out the door. It is better to know you have gotten the ball rolling from the beginning.

How did you convince administration it was worth building out a dedicated same-day discharge lounge and were you able to quantify any savings?

Dr. Wang: One of the most compelling arguments for us was the publication by Dr. Amit Amin in JACC Interventions in 2017¹ that showed the cost saving for both radial access and same-day PCI discharges based on Medicare claims data. When you look at the reimbursement challenges we face in the state of Maryland, it was very appealing. Our administration is very progressive, and likes to innovate and differentiate from our competitors. When we factor in the patient experience, this completely transforms the cardiac catheterization experience. It is also important to look at workflow and how it plays a role in unintended cost savings. In our cath lab, we have a separate prep and recovery area where our PCI patients spend the night. If we have a patient that comes from that area and then subsequently goes to the radial lounge, we have just freed up a bed for an incoming transfer earlier in the day, thus getting sicker patients sooner to the cath lab. It prevents late transfers and having to bring in the call team, paying the staff overtime, doing cases you have known about all day late at night, etc. This enables a much better workflow. There is also another reality regarding the patients who are kept overnight. The priority each morning is getting the first patients into the lab, thus the patients who are waiting to be discharged never get out of the hospital as early as we would like; it is just the reality. In my opinion, it is the efficiencies of having a same-day lounge that may not be easy to quantify, but clearly are responsible for cost savings. 

Cheryl: I absolutely agree. We have an excellent interventional program, and this was another way to further differentiate our program locally, if not nationally. We visited other programs who had lounges and we didn’t want to just build a lounge, but instead design something that would encompass and embrace a patient care pathway with an exceptional patient care experience. Our administration fully supported this effort. In addition, we believe it is important not to just plan for today, but to always have an eye towards the future. We keep in close contact with industry so we are aware of their pipeline and how it may impact our service, as well as healthcare economics. This allows us to build for our current needs and assures we have flexibility for changes we expect in the years to come. As to immediate savings, we recognized that we needed fewer staff at night for overnighting patients, but the more we get into value-based medicine, we have found that the patient experience has a significant role in how we get paid and this lounge is proving to have a very positive outcome on our patient experience scores.

Please describe the staffing and functional elements of the lounge as it relates to how many patients you can manage, hours of operation, nursing-to-patient ratio, etc.

Dr. Wang: By having a radial lounge, we have co-localized a group of healthier patients together. Mentally, patients feel better when they are in an environment surrounded by other healthy patients. We have 8 patient bays with lounge chairs that can recline flat. The patient is in this bay for approximately one hour after their procedure with the TR Band (Terumo) in place. The patient then gets dressed and moves out into an area that is more like an airport sky lounge, where they enjoy various amenities (e.g., wifi access, large-screen TV, reading nook, self-serve café) with their families. Diagnostics cath patients are leaving in an hour and a half, and interventions in approximately six hours, thus the lounge never looks like it is full; patients are constantly moving in and out. Since this is a same-day discharge lounge, we can expand its use to other procedures, one example being pre-hydration for transcatheter aortic vascular replacement (TAVR) computed tomography (CT) scans; no need for these patients to be in a hospital bed. Currently, the lounge operates from 7 am to 7 pm. 

Cheryl: When we look at typical recovery staffing, we have clearly defined ratios of nurses to patients; normally we see a 1:1 ratio initially and then 1:2, and then potentially 1:3. But in the radial lounge, that is not the case. All of that 1:1 and 1:2 had to do with checking the groin and checking for bleeding. This traditional observational contact isn’t really the case for radial patients and therefore, allows us to staff the lounge differently. We find that 2 nurses and 1 medical assistant working as a cohesive team is all that is necessary throughout the day to manage 8 to 9 patients. Because of our design and the patient flow, the lounge is dynamic and feels far less demanding than your traditional recovery space. Furthermore, as nurses, we tend to pay more attention to the sickest patients, but in the lounge, the patients are more alike, not needing specialized attention, thus it is more predictable and a pleasant atmosphere.

Are you amenable to having anyone visit your lounge to see it in operation?

Dr. Wang: I absolutely welcome this. With respect to a radial lounge, it is certainly not ‘one size fits all’. Individual programs considering a radial lounge will need to see how it will fit with their workflow, space constraints, procedures and policies, practice patterns, etc. I think it is very helpful when we can sit down with other programs, and discuss their challenges and exchange ideas. We would be happy to share our protocols and processes with anyone who wants to take the time to visit.

Cheryl: I absolutely welcome visitors. It was very valuable when we visited other programs, so I can understand and appreciate how important a site visit can be. From an administrator’s point of view, I would gladly welcome and offer my views and experiences to others. I think it may be valuable for them to understand what I would do differently and why, and what decisions we made to make it work for our program.

If you have questions about Union Memorial’s program, Dr. Wang and Cheryl can be reached via email, at john.wang@medstar.net and cheryl.lunnen@medstar.net.

Reference

1. 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; 10: 342-351.