Mazen Abu-Fadel, MD, MBA, FSCAI; Jayant Bagai, MD, FSCAI

For patients undergoing an elective percutaneous coronary intervention (PCI), the balance between optimal post-PCI monitoring (i.e., length of stay) and patient safety is of utmost importance. In 2018, SCAI published an expert consensus document update on length of stay post-PCI.¹

As PCI practice and outcomes continue to evolve and rates of post-procedural complications continue to decline, multiple studies have demonstrated the safety of same-day discharge (SDD).^2,3 The main reason early discharge is feasible and safe is that most post-PCI complications occur within the first six hours after the procedure. Late complications usually occur more than 24 hours post-PCI and are, therefore, not impacted by a routine overnight stay. A strategy of decreased length of stay improves patient experience and would impact a decline in healthcare costs. In this Tip of the Month, we focus on strategies that can help interventional cardiologists have a successful SDD program.

Salient Points for SDD

The most important aspect of SDD is to have a patient-centered protocol at your institution that allows close observation during recovery, a smooth discharge process, and next-day phone follow-up. Transradial PCI has played an important role in decreasing vascular complications and making SDD feasible. However, SDD is not limited to transradial PCI. Vascular closure devices for femoral access facilitate early post-procedural ambulation and can facilitate SDD.⁴

SDD depends on meeting specific patient safety milestones prior to actual discharge. The most effective way to ensure readiness for discharge is to address the “three Ps”: patient, procedure, and program. SDD should be feasible for all patients who pass these milestones before, during, and after the procedure.¹ This is true irrespective of the indications for the procedure and the patient’s presentation.

• Patient: Clinical stability is the cornerstone of this milestone. The patient should be at baseline before and after the procedure with no change in functional or mental status. As long as the patient is at baseline and satisfies all other criteria for SDD, the patient should be able to go home, irrespective of baseline comorbidities such as diabetes, congestive heart failure, or chronic lung disease. If at any point before, during, or after the procedure the patient experiences a decompensation of an underlying condition or develops new clinical symptoms such as continuing angina, reaction to iodinated contrast, or decompensated heart failure, SDD should be avoided and the patient should be observed overnight or longer if needed.

• Procedure: A stable and successful procedural outcome is the cornerstone of SDD. Even though the type of procedure itself is less of a factor (such as unprotected left main or chronic total occlusion PCI), some high-risk procedures such as mechanical circulatory device-supported PCI or last remaining vessel PCI should be considered for overnight stay. If at any point during or after the procedure there is a complication, including but not limited to an angiographic or vascular access site complication, peri-procedural myocardial infarction (MI), significant bleeding, or potential complicating factors such as use of excessive contrast volume, the patient should be observed until the resolution of the complication. Another important aspect is the ability of the patient to obtain dual anti-platelet therapy (DAPT) on the day of discharge and continue it uninterrupted at home. There are a number of patient-centered approaches and aids that one can utilize to help in stratifying which patients are safe for SDD and which need further observation.⁵

• Program: The support of the hospital system and administrators is important for a successful SDD program. This includes appropriate post-procedural care and medication administration by nursing staff, who should provide necessary education, discharge instructions, follow-up appointments, and confirmation that the patient has appropriate transportation home and will not be left alone for the first 24 hours after SDD. Ideally, prescriptions for DAPT should be filled or delivered to the patient prior to discharge. A phone call within 24–72 hours and a follow-up visit within two to four weeks of discharge should be arranged. A comprehensive nursing discharge checklist that covers all these elements is included in the SCAI expert consensus document.¹

Conclusion

The final decision to discharge a patient after a PCI remains an individualized medical decision based on the patient, procedure, and its outcomes. However, SDD is safe and feasible if the appropriate milestones presented above are applied systematically and followed closely. 

References 

1. Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2018 Oct 1;92(4):717–731.
2. 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 Oct 5;306(13):1461–7. 
3. Bundhun PK, Soogund MZ, Huang WQ. Same Day Discharge versus Overnight Stay in the Hospital following Percutaneous Coronary Intervention in Patients with Stable Coronary Artery Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS One. 2017 12(1): e0169807.
4. Yee KM, Lazzam C, Richards J, et al. Same-day discharge after coronary stenting: a feasibility study using a hemostatic femoral puncture closure device. J Interv Cardiol. 2004 Oct;17(5):315–20. 
5. Amin AP, Crimmins-Reda P, Miller S, et al. Novel Patient-Centered Approach to Facilitate Same-Day Discharge in Patients Undergoing Elective Percutaneous Coronary Intervention. J Am Heart Assoc. 2018 Feb 15;7(4): e005733