Same-Day Discharge is Preferred by the Majority of the Patients Undergoing Radial PCI

Although diagnostic cardiac catheteriazation is usually performed on an out-patient basis, overnight stay is still the standard approach for the majority of patients undergoing percutaneous coronary intervention (PCI). The main reasons for this are the risk of entry site complications and subacute occlusion of the target vessel after discharge. The primary advantages of same-day discharge PCI are the potential reduction in cost and better utilization of hospital beds. There is now increasing data in the literature that same-day discharge is a safe approach for low-risk patients undergoing PCI.1–6 However, there is very limited data on patients’ preference for same-day discharge PCI.2 In our retrospective study we contacted 943 patients who underwent radial PCI between 1998 and 2001 and who were discharged on the same day of the procedure and evaluated their satisfaction with same-day discharge. Methods A total of 3,532 PCI procedures were performed in our hospital between April 1998 and March 2001. Of these, 2,072 (58.6%) were done using the radial approach. Among this number, 943 (45.5%) of the patients who had radial PCI were discharged on the same day of the procedure. Prospective data on patient demographics, procedural outcome and complications were stored in our cath lab database. Patients who underwent same-day discharge PCI were mailed a standardized questionnaire and contacted by phone. They were asked if they were satisfied with same-day discharge following PCI, how important it was for them to be discharged quickly, if they were reluctant to be discharged on the same day of the procedure, and if they had any difficulty finding transportation home. They were also asked to report any access site complications, repeat angiogram and/or PCI, or any other complications during the first 24 hours and the first month post-discharge. For patients who did not respond, we contacted their referring doctor in order to check their health status. Health status and need for repeat angiogram/ PCI during the first month post-PCI were also verified by accessing vital statistics and our province-wide cath lab database. Our institution is the only referring center providing tertiary cardiac care (PCI, CABG, EPS) for all hospitals and physicians on Vancouver Island. Radial PCI technique. All patients undergoing radial PCI in our hospital are checked for adequate collateral circulation (+Allen test). PCI is performed using 6 or 7 French (Fr) catheter equipment via the right or left radial artery under local anesthesia and sedation. Radial artery cannulation is accomplished using a Cook needle with a small 21-gauge cannula and a 0.018-inch guidewire. A hydrophilic 6 or 7 Fr sheath (Terumo Medical Corp., Somerset, New Jersey; Cook Inc., Bloomington, Indiana) is inserted in the radial artery and a vasodilating cocktail containing 200 mcg of nitroglycerin and 1 mg of verapamil is usually administered. All patients are pre-treated with aspirin, and clopidogrel or ticlodipine. Intravenous heparin 5,000 to 10,000 IU is given before the PCI and ACT is checked at the discretion of the operator. Patients who receive a stent are prescribed clopidogrel 75 mg o.d. (or previously ticlodipine 250 mg b.i.d.) for 4 weeks. After successful PCI, the sheath is immediately removed and a pressure clamp is applied. Same-day discharge PCI. Patients who were discharged on the same day during the study period were those with stable and unstable angina (CCS class I–IV), type A, B, or C lesions, single or multivessel disease and undergoing single or multivessel PCI. Patients selected for overnight or longer stay in the hospital had one or more of the characteristics outlined in Table 1. For patients with any of these characteristics, same-day discharge was either not feasible (access site complications, administration of IIb/IIIa inhibitors, etc.), or was considered of increased risk for post discharge complications and thus not safe (suboptimal PCI result etc). Some patients were not discharged for social reasons including elderly patients living by themselves and distance from access to medical care. After successful PCI, the radial sheath is immediately removed and a pressure clamp is applied. The clamp is removed within 2 to 3 hours from the procedure if hemostasis has been achieved. A pressure bandage and a sling are then applied and patients are fully ambulated. If there are no complications (chest pain, entry site complications) after 1 hour of ambulating, they are allowed to leave the hospital. Patients living more than 100 km from the hospital are requested to seek local overnight accommodation and arrange for their own transportation home with an accompanying driver. Patients are asked to remove the pressure bandage and the sling the next morning and to visit their own physician for follow-up after 7 to 10 days. Statistical analysis. Continuous variables are presented as mean ± SD. Categorical data are presented as percent frequency. SPSS 10 for Windows was used for the statistical analysis. Differences between group means were tested by the Student’s t-test. Categorical variables were compared using chi-square. A p value 0.05). The percentage of men who were satisfied was significantly greater comparing to women (91.7% vs. 80.3% respectively, p 0.05). A total of 278 patients (34.2%) reported access site complications within 24 hours post-discharge. All of the complications were minor and none of the patients required a transfusion or surgical repair. Patients without vascular complications within 24 hours were significantly more satisfied with same-day discharge (91..5%) than those with vascular complications, (83.4%, p 0.05). For 390 (48.1%) patients, it was important to be discharged on the same day of the procedure. These patients were significantly more satisfied with same-day discharge (97.9% satisfied vs. 79.7% when early discharge was not important, p 0.05). The percentage of men who were reluctant was significantly less compared to women (28.1% vs. 46.1%, p 0.05). This shows that patients understand that overnight stay will not make any difference in the need for a repeat procedure. It is also interesting that significantly more men were satisfied with same-day discharge compared to women (91.7% vs. 80.3% respectively, p Study limitations. A limitation of our study is that the questionnaire utilized in the study has not been validated. Another limitation is that elderly patients and those with difficult access to medical care had the option of staying overnight, which may have increased patient satisfaction scores. Also, our study is retrospective, so patients’ opinion was not evaluated immediately after PCI. Patients may therefore have underestimated or forgotten any possible features of same-day discharge that they disliked. Furthermore, patients may have been reluctant to express dissatisfaction to caregivers and representatives of the hospital. Quality of life surveys performed early after discharge can probably more effectively assess patient opinion on same-day discharge. Conclusion Our study shows that the majority of patients were satisfied with same-day discharge following radial PCI. Few studies have examined the cost effectiveness of eliciting preferences and have suggested that such efforts in certain therapies may be cost-effective.20,21 This overwhelming preference for same-day discharge PCI should thus be used as another argument for this approach along with its proven safety.

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