The American College of Cardiology (ACC) has issued new guidance encouraging same-day discharge (SDD) for lower-risk adult percutaneous coronary intervention (PCI) patients in certain cases, which the organization said could reduce related health system costs by as much as 50%.
SDD is also shown to improve safety and outcomes for many, while other data suggest it is the preference for the majority of patients.
The 2021 ACC Expert Consensus Decision Pathway (ECDP) was published online Thursday in the Journal of the American College of Cardiology, with a writing committee led by Duke Clinical Research Institute’s Sunil V. Rao, MD. It is the result of a working group running since October 2018.
The document includes a checklist – available as a digital version on ACC.org – aimed at assisting shared SDD decision-making between doctors and patients in pre-procedural, peri-procedural and post-procedural stages. It also lays out clinical scenarios that consider the rationale for SDD versus overnight monitoring.
The ECDP also stipulates cases in which SDD should not be considered, including in patients presenting with ST-elevation myocardial infarction (STEMI) or non–ST-elevation myocardial infarction (NSTEMI). The pathway does not address the role of SDD in a pediatric population.
Pre-procedural considerations in the checklist include social factors such as the patient being willing to go home, having a caregiver available if needed, and the ability for the patient or caregiver to call 911. It also covers staffing and systems issues at medical centers, such as being able to schedule PCI early enough in the day to allow a reasonable pre-discharge observation period.
Post-procedural factors include clinical issues like complications during or after PCI, the success of the PCI, exacerbation of disease and change in mental status from baseline. The ECDP stresses that patient willingness to go home should be a crucial deciding factor after PCI.
The pre-discharge section of the checklist includes ensuring plans have been made for loading dose administration and subsequent prescriptions of P2Y12 inhibitors (P2Y12i), prescriptions for aspirin and statins, referrals to cardiac rehabilitation, and follow-up calls and appointments with patients.
It also ensures education has been provided over monitoring the access site and ensuring emergency contacts are in place.
Not suited for SDD
Besides patients with STEMI and NSTEMI, the ECDP stipulates that patients for whom large-bore femoral sheaths have been used – for example, of 7 F or more – overnight monitoring could be considered “given some concern for the elevated risk of late bleeding compared with the use of smaller-caliber sheaths”.
The ECDP does apply to both transradial and transfemoral access, however.
Patients with STEMI or NSTEMI should also be hospitalized as inpatients for at least 1 night to allow postprocedural monitoring, the document states.
The checklist tool is applicable to staged procedures performed after the index PCI for patients who initially presented with NSTEMI or STEMI, though, the experts added. This includes those undergoing a staged PCI during the index hospitalization for NSTEMI or STEMI, or patients who are discharged home and return for a planned staged PCI.
The experts also stressed that a final decision on SDD should only be made after all items on the checklist have been answered, which may not occur until after the procedure.
Guidance, not policy
Overall, the ECDP should be used only to inform the development of various tools that accelerate real-time use of clinical policy at the point of care, the experts said, stressing that they are not intended as a “single correct answer.”
“Rather, they encourage clinicians to ask questions and consider important factors as they define treatment plans for their patients.”
The recommendations are made under the assumption that discharge instructions over the P2Y12i, how to monitor the access site and confirmation of appropriate outpatient follow-up will be adapted to conform with the protocols of individual institutions, the experts said.
“The checklist offers considerable scope for adaptation to suit individual practice patterns,” they said, adding that individual facility systems will determine when and by whom the checklist will be completed.
Implementation of safe and effective SDD will depend on identifying specific team members responsible for its delivery, the experts added, encouraging “physician-champions” to meet with staff administrators to present safety data for PCI and promote use of the checklist.
“In addition to the outpatient cardiology clinical staff and cardiac catheterization laboratory operational staff, other members of the cardiovascular team, including pharmacists, staff in the preprocedural or postprocedural areas, and those who work in registration, may play the greatest role in implementing the SDD checklist.”
Benefits of SDD
“PCI has evolved in safety and efficacy such that many patients can leave facilities the same day as the procedure, with retrospective data showing no increase in death or rehospitalization compared with patients who stay for overnight monitoring,” the experts said, citing previous research led by Rao.
“In addition, SDD is preferred by patients and can increase savings and bed capacity.”
In particular for safety in terms of major adverse cardiovascular events, meta-analyses have found no difference between same- and next-day discharge following PCI, they said, adding that hospital-acquired infections and post-hospitalization syndromes are risks for inpatients.
Studies have also found that SDD for PCI is associated with a relative reduction of as much as 50% in health system costs, the experts said. SDD for PCI also leads to a reduction in supplies and room and board costs, they added, “2 significant areas that drive savings.”
They cited data showing a minimum savings of $5,000 per case for SDD after PCI, increasing up to $7,000 in the radial access setting.
“It is estimated that the use of SDD in 50% of elective PCIs would result in savings of $200 million to $500 million per year for U.S. healthcare systems,” they added.
The experts conceded that uncertainty remains after SDD for PCI due to the largely observational nature of the data, with only small randomized trials in support. The experts, though, aired their hopes that the ECDP can help address this uncertainty.
Implementation of the checklist should widen the pool of patients who can safely undergo SDD, the experts said, leading to greater patient satisfaction and awareness and increased savings within facilities.
“Implementation of this checklist also provides institutions with an opportunity to carry out quality evaluations as data from the checklist can be used to inform the evolution of future checklists and protocols in SDD for PCI.”
Rao SV, Vidovich MI, Gilchrist IC, et al. 2021 ACC Expert Consensus Decision Pathway on Same-Day Discharge After Percutaneous Coronary Intervention. J Am Coll Cardiol 2021 Jan 7. doi: 10.1016/j.jacc.2020.11.013. (Article in press)