Implementing a Same-Day Discharge Pathway After a PCI

Maximillian Bourdillon, MD; Konstantinos Charitakis, MD, FSCAI; Konstantinos Dean Boudoulas, MD, FSCAI

Introduction

Same-day discharge (SDD) pathways have become increasingly commonplace¹ with the iterative advances in the percutaneous coronary intervention (PCI) technique, prompting an American College of Cardiology (ACC) Expert Consensus Decision Pathway and SCAI Expert Consensus Statement on Percutaneous Coronary Intervention Without On-Site Surgical Backup.²^-3 Broadly, an SDD is defined as a post-PCI procedure stay without supervised overnight monitoring in a hospital or facility outside of routine monitoring (i.e., access site) with discharge within 12 hours after arrival to the facility.

In this Tip of the Month, we highlight the optimal patient selection and conditions for an SDD.

Benefits of an SDD After a PCI

The advantages of an SDD after a PCI include improved patient satisfaction³ when compared to routine overnight monitoring and reduced nosocomial infections and hospital-associated adverse events (i.e., falls), as well as cost benefits to the health system with improved bed capacity and hospital throughput. It is estimated that an SDD of half of U.S. patients undergoing an elective PCI would translate into annualized savings of $200-500 million.² Overall, rates of an SDD are rising, and an SDD has not been associated with adverse outcomes.¹ Notably, most post-PCI complications occur within the first six hours post-procedure, and late complications usually occur more than 24 hours post-PCI and are not impacted by routine overnight monitoring.

Patient Selection

Broadly, any patient presenting for an elective, nonurgent PCI on an outpatient basis can be considered for an SDD. On the other hand, while patients presenting with acute coronary syndrome should undergo closer monitoring, staged procedures at the end of an index hospitalization (i.e., completed revascularization of a nonculprit lesion) can also be considered. Further procedural characteristics such as procedure complexity (e.g., unprotected left main intervention, chronic total occlusion, atherectomy use) must be taken into consideration based on operator judgment and institutional best practices.

Suitable patients for an SDD should have adequate social support with adequate caregiver support to stay with the patient overnight following discharge, help with activities of daily living, and access to emergency services. Ideally, patients are identified by the operator pre-procedure, based on procedural and anatomic considerations and the patient’s motivation to proceed with an SDD after a PCI can be affirmed. Such pre-procedural planning can facilitate coordination with schedulers, catheterization laboratory staff, and pharmacy in tandem with the patient and their caregiver to proactively identify potential barriers to an SDD.

Once patients have undergone a PCI, there are several opportunities to reassess candidacy for an SDD. First, patients must have undergone a successful PCI without complications. Routine post-procedure vascular access site monitoring is crucial in this regard, especially in tandem with vascular closure devices and bore femoral access larger than 6 French (Fr) for more complex procedures. However, success of a PCI is only one factor to consider. Patients’ clinical status should be comprehensively evaluated for evidence of stroke or changes in mental status, bleeding, allergic reactions, angina, heart failure, electrocardiogram (ECG) changes, arrhythmia, and/or exacerbation of chronic medical conditions (e.g., chronic obstructive pulmonary disease [COPD], congestive heart failure, hypertension, diabetes mellitus), among others.

Checklists

The 2021 ACC Expert Consensus Decision Pathway highlights the use of checklists to identify patient suitability for an SDD pre-procedure, post-PCI, and pre-discharge.

Table 1. Pre-Procedure and Post-PCI Checklist for SDD

Pre-Procedure Evaluation	Proceed to Post-Procedure Evaluation	Recommend Overnight Monitoring
1. Does the patient have acute coronary syndrome?	No	Yes
2. Do any staff feel that the patient is not a candidate for an SDD?	No	Yes
3. Does the patient have adequate caregiver support?	Yes	No
4. Can the patient or caregiver call 911?	Yes	No
5. Is the patient motivated to be discharged on the same day?	Yes	No
6. Is the patient scheduled early enough so they can be sufficiently observed and discharged in a reasonable amount of time?	Yes	No
Post-Procedure Evaluation	Proceed to Pre-Discharge Checklist	Recommend Overnight Monitoring
7. Were there any procedural complications?	No	Yes
8. Was the PCI successful?	Yes	No
9. Is there any clinical instability?	No	Yes
10. Is there an exacerbation of chronic disease?	No	Yes
11. Is the patient’s mental status stable from presentation?	Yes	No
12. Is the patient willing to be discharged?	Yes	No

Once the patient has met the criteria for discharge, it is essential to ensure appropriate follow-up, instructions regarding pharmacotherapy are provided, and access to crucial prescriptions. The Pre-Discharge Checklist (Table 2) provides opportunities for multidisciplinary coordination among clinic staff, catheterization lab staff, pharmacists, and patient/caregiver dyad to ensure safe and optimized discharge planning. Unique opportunities for quality improvement initiatives, such as bedside medication delivery, could enhance institutional practices for all patients regardless of utilization of an SDD pathway.

Table 2. Pre-Discharge Checklist

Pre-Discharge Checklist

Confirm the loading dose of the P2Y₁₂ inhibitor that was administered.
Confirm the patient has received at least a 30-day prescription for a P2Y₁₂ inhibitor.
Confirm the prescription for aspirin and a statin.
Confirm the cardiac rehabilitation referral.
Confirm the name of the clinical staff member who will follow up by telephone with the patient on the day after discharge.
Provide education regarding access site monitoring and the importance of dual antiplatelet therapy (DAPT) adherence, as prescribed.
Provide an emergency number to call.
Schedule a follow-up appointment.

The operator agrees an SDD is reasonable with any additional amendments in accordance with local practice or institutional best practices.

Conclusions

An SDD can provide many benefits to patients and health systems, and in certain health systems, it is the predominant model of care following an elective PCI.⁵ Further, an SDD is being increasingly studied following a complex PCI.⁶ Implementing an SDD pathway following a PCI necessitates multidisciplinary coordination between inpatient teams (e.g., primary team, catheter lab, pharmacy) and facility staff, as well as local administrators, to identify barriers to an SDD and potential quality improvement initiatives to facilitate an SDD.

References

Bradley SM, Kaltenbach LA, Xiang K, et al. Trends in Use and Outcomes of Same-Day Discharge Following Elective Percutaneous Coronary Intervention. JACC Cardiovasc Interv. 2021 Aug 9;14(15):1655-1666.
Rao SV, Vidovich MI, Gilchrist IC, et al. 2021 ACC Expert Consensus Decision Pathway on Same-Day Discharge After Percutaneous Coronary Intervention: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021 Feb 16;77(6):811-825.
Grines CL, Box LC, Mamas MA, et al. SCAI Expert Consensus Statement on Percutaneous Coronary Intervention Without On-Site Surgical Backup. JACC Cardiovasc Interv. 2023 Apr 10;16(7):847-860.
Glaser R, Gertz Z, Matthai WH, et al. Patient satisfaction is comparable to early discharge versus overnight observation after elective percutaneous coronary intervention. J Invasive Cardiol. 2009 Sep;21(9):464-467.
Taxiarchi P, Kontopantelis E, Martin GP, et al. Same-Day Discharge After Elective Percutaneous Coronary Intervention: Insights From the British Cardiovascular Intervention Society. JACC Cardiovasc Interv. 2019 Aug 12;12(15):1479-1494.
Taxiarchi P, Kontopantelis E, Kinnaird T, et al. Adoption of same day discharge following elective left main stem percutaneous coronary intervention. Int J Cardiol. 2020 Dec 15;321:38-47.