Same-Day Discharge in Appropriately Selected Patients is Safe

Dr. Sunil Rao and colleagues conducted a study to examine the prevalence of same-day discharge among older individuals following percutaneous coronary intervention (PCI), and the rates of death or rehospitalization.¹

The study included data from 107,018 patients 65 years or older undergoing elective PCI procedures at 903 sites participating in the American College of Cardiology (ACC) CathPCI Registry between November 2004 and December 2008, and were linked with Medicare Part A claims. Patients were divided into 2 groups based on their length of stay after PCI: same-day discharge or overnight stay. The primary outcomes measured were rehospitalization or death occurring within 2 days and by 30 days after PCI.

Prevalence of same-day discharge was 1.25% (n = 1,339 patients), with significant variation across facilities. There was no significant difference in the rates of procedural success between the 2 groups. Patient characteristics were similar between the 2 groups, although same-day discharge patients underwent shorter procedures, with less multi-vessel intervention. Patients who were discharged home the same day were more often categorized in the lowest quintile of predicted risk for death or rehospitalization, while there were approximately equal proportions of lower- and higher-risk patients observed overnight.

“There were no significant differences in the rates of death or rehospitalization at 2 days (same-day discharge, 0.37% vs. overnight stay, 0.50%) or at 30 days (same-day discharge, 9.63% vs. overnight stay, 9.7%). Among patients with adverse outcomes, the median time to death or rehospitalization did not differ significantly between the groups (same-day discharge, 13 days vs. overnight stay, 14 days). After adjustment for patient and procedure characteristics, same-day discharge was not significantly associated with 30-day death or rehospitalization,” the authors write.

Cath Lab Digest spoke with Dr. Rao about this study and his own experience with same-day discharge at the Durham VA Hospital.

Why look at same-day discharge and what did you learn?

One of the reasons we did the study was to look at the prevalence of same-day discharge in the United States. Anecdotally, it is much more common outside the U.S. I don’t know exact numbers, but certainly when we have done PCI trials through the Duke Clinical Research Institute, many patients do go home the same day, and outside the U.S., it is not just elective PCI patients, but even patients who come in with acute coronary syndrome will often go home the same day as their PCI. It is actually very unusual in the United States for patients to go home the same day as their PCI. In our study, the overall prevalence was only about 1.25%.

Our major finding was that many patients who are eligible for same-day discharge in fact stay overnight in the hospital. This leads to a great deal of resource use. I think that same-day discharge in selected patients is actually a very efficient care strategy. The other thing that we found was that the vast majority of patients undergoing elective PCI actually have excellent outcomes, something for which we should congratulate ourselves. The dramatic evolution in device technology and pharmacotherapy means that by and large, outcomes among elective PCI patients are excellent. Complication rates are low. Patients at risk for death or readmission, the study endpoint, did not show any difference whether they stayed overnight for observation or went home the same day. We looked at Medicare patients, so these are patients who are already over the age of 65 and automatically at higher risk than the garden-variety PCI patient who is younger than 65.

I work at Duke Medical Center and I also work at the Durham VA. At the VA, we have had a successful same-day discharge strategy for about 2 years. We choose our patients very carefully, as you can imagine. It is not just about choosing patients at low clinical risk. The patient must be an elective PCI, have a successful procedure without any complications, and be ambulatory before they are discharged. Patients also must have a social support network at home. This is an important part of a same-day discharge strategy. You do not want to consider patients who live by themselves at home, because if they do have a complication, they have no one to rely on. At the VA, we have a protocol and a pathway, so that when patients do go home, they are not left out there on their own. They also have a number they can call with any questions or problems.

Could you give an example of what is considered low risk and what might be considered borderline?

That is actually one of the things that we hope comes out of this paper: recognition that we need better risk assessment tools. In our study, when we looked at the predicted risk for 30-day death or readmission, and we separated the overnight stay patients by the predicted risk, it didn’t matter if the patient was at high predicted risk or at low predicted risk. Physicians could not tell the difference between a patient who was high risk or low risk, so it appears that they are genuinely concerned about their patients so they default to keeping these patients in the hospital overnight. However, physicians seemed to be quite good, when we looked at same-day discharge patients, at distinguishing very low risk cases. We do need better risk assessment tools in order to more precisely identify patients who can safely go home the same day and those who might in fact benefit from an overnight stay. There are some guidelines as to who can go home the same day after a PCI, but generally, that patient is going to be someone who has an elective procedure, with no bleeding complications (the radial approach reduces bleeding complications so much that transradial PCI is a much safer procedure) and again, they need to have a social support network at home, be able to take their medicines and be adherent to them.

Is the transradial approach an essential part of a same-day discharge program?

I don’t think it is an essential part, but it is certainly a helpful one, because the bleeding rates are so low. There is a single-center study out of Mount Sinai in New York that showed if you use a vascular closure device, your rates are low enough that you can send patients home the same day.²

Can you tell us more about the program at the Durham VA?

We adopted the radial approach almost 6 years ago and are a ‘radial first’ institution. As part of that, we realized that many patients were staying overnight after PCI when they didn’t need to. They were sitting in their bed with a wristband on, and were able to walk around and go to the bathroom. It just did not make sense to us as to why these patients couldn’t go home.

When we implemented our same-day discharge strategy, we said, okay, the patient we are going to send home the same day is a patient:

• Who had a successful radial procedure with no intraprocedural complications;
• No post procedure bleeding complications; 
• Is ambulatory;
• And who has someone to go home to.
• We also decided that our same-day discharge patients have to live within 60 miles of the medical center. Many of our veterans come from quite a distance, and we did not want them getting into trouble and then not being able to access a medical center quickly. The distance limitation was somewhat arbitrary. 

We implemented this strategy in January 2009. We see all of our PCI patients back at 30 days and have a very specific assessment of whether they were sent home the same day or not, and if they had any interim events. We are selective, and patients have done well. In fact, none of them have had any complications after same-day discharge. Patient selection is very important. Most of our patients actually do not qualify because they live more than 60 miles from the medical center.

Is the choice left up to physician discretion?

It is absolutely left up to the physician. They should be the one who decides which patient can go home which patient should stay overnight.  The only guidelines are those from the Society of Cardiovascular Angiography and Interventions (SCAI).³ We co-opted some of their guidelines when we developed our protocol for same-day discharge, using it as a template to get started. Another nice thing about the VA hospital is that all the care is paid for, and so there is no financial incentive for us to keep anyone overnight. In fact, there is no financial incentive in the private sector either, since the payment is the same whether the patients are observed overnight or are discharged the same day.

The financial issue is a complicated one. I think it is an important aspect. From a billing perspective, there are two types of PCIs: outpatient and inpatient. An outpatient PCI is declared as an outpatient and has to go home within 23 hours. If they stay at the hospital for longer than 23 hours, they become an inpatient PCI. The financial difference between an inpatient PCI and an outpatient PCI for the hospital, a non-VA hospital, is substantial. Hospitals get paid almost three times more to have an inpatient than an outpatient PCI. Payers have become very sensitive to this and it has resulted in some high-profile audits of hospitals. Hospitals can have penalties levied against them if patients who either started as outpatients were converted to inpatients without a justification, or if there are patients who were actually called inpatients without a justification. There are some justifications, however, such as if a patient has a procedural complication, for example, you can keep them as an inpatient. Medicare has certain high-risk criteria justifying an inpatient stay, but the vast majority of patients really can be done as outpatients (≤ 23 hours of stay). So in this era of greater scrutiny, hospitals have become much more aware of what is and is not an outpatient. Hospitals are paid the same amount for an outpatient whether the patient stays 23 hours — that is, overnight — or whether they go home the same day. The difference, from the hospital perspective, is whether the bed is occupied or not. Nurses must be hired to take care of these patients, they are put on a monitor, and resources must be spent. Same-day discharge doesn’t make sense for every medical center. It does make sense for medical centers that are major referral centers. If you have a patient with an elective PCI who theoretically could be sent home, but you keep them overnight, they are occupying a bed that perhaps another hospital, that really has a sick patient, and wants to transfer that patient to you, needs, and therefore, you are delaying transfer. Same-day discharge can potentially increase bed availability. If we ever get to the point that there are going to be bundled payments for PCI, which sounds like it is something being proposed, obviously the faster you get patients out of the hospital, the more margin you make for the hospital. Much of this tied up in billing and financial incentives, and it is a rapidly changing area.

From the physician perspective, I think physicians keep people in the hospital overnight because they are genuinely worried about their patient. They are saying, I can’t tell whether or not you are going to have a problem, and so I would rather just keep you overnight just to be safe. Our study shows that you can confidently send many of these patients home the same day without an increase in risk. We call for a randomized trial, but the reality is that no one is going to pay for a randomized trial of same-day discharge versus overnight stay, so what I would like to see is a demonstration project on the part of either Medicare or the payers, to prospectively evaluate this kind of efficient care strategy and see whether there is an increase in risk associated with same-day discharge. If there isn’t, it will save payers so much money that, quite frankly, they should incentivize same-day discharge for some patients.

What if a center is thinking of getting started?

Regardless of what kind of a center it is, if they are thinking about having a same-day discharge strategy, a pathway and protocol needs to be in place, as well as patient education. Some patients will not feel comfortable going home the same day, and that is fair. My guess is that the vast majority of patients would prefer to be at home rather than the hospital, but if patients are sent home the same day, make sure they have a list of instructions. Make sure you educate patients about what to expect when they get home, in terms of their vascular access site or having recurrent chest pain. Make sure they know what number to call in case they run into trouble. Same-day discharge is only for centers that are willing and able to set up this kind of program.

A majority of activities can be quickly resumed if the radial approach is used, because patients do not have to worry about walking or resuming their normal activities. But even with the radial approach, there are some things that people need to watch out for, such as swelling or pain.

At the VA, patient education is done at discharge. The patients get a formal talk from the nursing staff in the discharge area at our VA. They are sent home with a sheet of paper that has a number to call if they have any problems and what to watch out for in terms of their vascular access site. Again, the majority of our patients are radial, and our same-day protocol says that our patients have to have a radial procedure, so patients are taught about that. Patients also have a list of their medicines and why they are taking each one. That is an important aspect as well, explaining not just what medications they are taking, but why. It also lists their follow-up appointment.

We see all patients 30 days after their PCI and patients are contacted 48 hours after their procedure to see if they are having any issues.

Can you talk about how the decision is made to discharge the patient the same day?

Our protocol is straightforward. In our pre-assessment clinic, where we see all patients referred for a cath, patients are flagged as eligible for same-day discharge. At that time, we discuss it with the patient. Ultimately, the decision rests with the operator, who has to be comfortable that the patient is eligible to go home the same day. Our protocol says that the patients who are excluded from going home the same day include any patient whom the attending physician feels uncomfortable sending home. That is a broad statement, but there are some intangibles with some procedures, where you say, I just do not feel comfortable with sending this person home the same day. That is a very fair reason to keep them overnight.

Let’s look at it from the private sector. We are not forcing people out, or recommending that patients be forced out the same day; we are saying that this is something that can be considered. If you look at the financial aspect, which unfortunately, in today’s world, we have to, hospitals do not get penalized either for sending patients home the same day or keeping them overnight. The payment is the same amount whether patients stay 23 hours or 6 hours. Still, it is important that everyone — the physicians, the nursing staff, and the patient — should agree that same-day discharge is a good idea.

Our study underscores the power of the ACC National Cardiovascular Data Registry to identify efficient processes of care that should be either adopted or further evaluated. That is one of the biggest advantages of hospitals belonging to the registry. I would encourage hospitals that are not part of the registry to join, because it improves the quality of care of PCI. The fact that we have come to a point in the evolution of PCI to be able to send patients home the same day is remarkable. When angioplasty was first invented, patients stayed in the hospital for 7 days. It is a tremendous change to have that procedure evolve to the point where patients can go home the same day.

Dr. Rao can be contacted at sunil.rao@duke.edu.

Dr. Rao reports no conflicts of interest regarding the content herein.

References

1. 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(13):1461–1467.
2. Patel M, Kim M, Karajgikar R, et al. Outcomes of patients discharged the same day following percutaneous coronary intervention. JACC Cardiovasc Interv 2010 Aug;3(8):851–858.
3. Chambers CE, Dehmer GJ, Cox DA, et al. Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Endorsed by the American College of Cardiology Foundation. Catheter Cardiovasc Interv 2009 Jun 1;73(7):847–858.