ADVERTISEMENT
Commentary
My Home is My Castle
October 2004
Suppose you need coronary angioplasty. Would you prefer to stay in the hospital overnight or would you prefer to go home a few hours after your treatment? The answer will depend on the balance between the comfort of sleeping at home, on the one hand, and your wellbeing after treatment and the risk of delayed post-procedural complications if no medical or nursing care is provided, on the other hand.
If you entered your hospital walking, if you had a quick, uneventful and successful procedure, were ambulatory immediately afterward, and if you still felt well 4 hours later…then I am sure you would think “Why can’t I leave this place? I can walk, I feel good and nobody is taking care of me anyhow. And the doctor told me that the stent result was optimal.” Most of our patients prefer treatment on an out-patient basis if you ask them before treatment.
Dr. Ziakas et al. demonstrated that 88.6% of patients indeed were satisfied with same-day discharge PCI, especially the younger patients with a high motivation to leave hospital the same day.1 Minor entry site complications and reluctance to be send home were the main reasons for dissatisfaction. Although patient preference is the most important motivation for striving toward out-patient treatment, other motives may also play a role.
Since the number of PCIs is still growing and the number of hospital beds is usually decreasing because of limited financial resources, cardiology wards may get blocked for patients requiring other forms of clinical cardiac care. Thus, out-patient PCI also increases patient flow through cardiology departments, contributing to shortened waiting lists and cost reductions.
PCI on an out-patient basis, however, has not (yet) been established as the routine approach. If risk of bleeding is extremely low and if risk of acute stent thrombosis following a perfect angiographic result is very low — both after a 4-hour observation period — what arguments are there to keep the patient in the hospital? Many reasons are cited, but none with a medical basis. Arguments against early discharge are based on legal, economic and historic reasons. Hospitals working in a so-called legal environment are more reluctant to discharge patients the day of treatment, afraid of the consequences that may ensue if a patient suffers a complication within 24 hours.
In other hospitals, the PCI is not reimbursed if performed on an out-patient basis simply because no code exists for this treatment strategy. Due to the essential shortcomings of reimbursement regulations by insurance companies, government and hospital management, there is no (financial) incentive to discharge the patient the same day since this will reduce bed occupancy and associated income.
There is also some conservatism among interventional cardiologists who simply do not accept the possibility of out-patient coronary angioplasty despite the publication of an increasing number of data.1–8 In 1990, we already questioned the reason to keep the patient hospitalized following an uneventful and successful coronary intervention via the brachial artery.2 After virtual elimination of bleeding complications following transradial coronary stenting, we started to actually discharge patients the day of treatment in 1994.3–5 In this very first experience on out-patient coronary stenting in a selected group of patients, no patient suffered a complication within the first 24 hours following the PCI.3 The reasons for overnight stay have been well summarized in the publication of Ziakas et al.1,6 and are almost similar to the criteria that we have applied for 10 years.
In summary, stable patients with an optimal angioplasty result without cardiac or vascular complications during the procedure and 4 hours after are suitable for out-patient treatment. Transradial access makes out-patient treatment more likely than femoral access, even when closure devices are used because of the possibility of immediate mobilization and because of the minimal risk for major entry site problems. Unstable patients and patients admitted for primary PCI are usually observed overnight. Administration of IIbIIIa blockers is usually a reason to keep the patient in the hospital, though this has been questioned by Gilchrist et al.8
Today, about three quarters of patients undergoing elective transradial coronary angioplasty are treated on an out-patient basis at our center. After 10 years of performing out-patient coronary angioplasty, we did not see any reason to become more restrictive. On the contrary, we are striving toward the extension of out-patient treatment, e.g., for those patients receiving IIbIIIa blockers.
I foresee a future where patients scheduled for coronary angioplasty are not received in a traditional hospital environment, but in a kind of “business class” lounge. In this lounge, the patients could comfortably wait for their procedure after being well informed and prepared. After PCI, the patient would return to the lounge where the observation period could be spent in comfortable chairs in front of a wide screen television or at reading tables or working corners. Just the way you would like to be treated…
1. Ziakas A, Klinke P, Mildenberger R, et al. Comparison of the radial and femoral approaches in left main PCI: A retrospective study. J Invas Cardiol 2004;16:129–132.
2. Laarman GJ, Kiemeneij F, van der Wieken LR, et al. A pilot study of coronary angioplasty in outpatients. Br Heart J 1994;72:12–15.
3. Kiemeneij F and Laarman GJ. Transradial artery Palmaz-Schatz coronary stent implantation: Results of a single center feasibility study. Am Heart J 1997;130:14–21.
4. Kiemeneij F, Laarman GJ, Slagboom T, van der Wieken R. Outpatient coronary stent implantation. J Am Coll Cardiol. 1997 Feb;29(2):323-7.
5. Slagboom T, Kiemeneij F, Laarman GJ, et al. Actual outpatient PTCA: Results of the OUTCLAS pilot study. Cathet Cardiovasc Interv 2001;53:204–208.
6. 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.
7. Clement-Major S and Lemire F. Is outpatient coronary angioplasty and stenting feasible and safe? Results of a retrospective analysis. Can J Cardiol 2003;19:47–50.
8. Gilchrist IC, Nickolaus MJ, Momplaisir T. Same-day transradial outpatient stenting with a 6-hr course of glycoprotein IIb/IIIa receptor blockade: A feasibility study. Cathet Cardiovasc Interv 2002;56:10–13.
