ACC.13: Stent and Send: Is Same-Day Discharge Post-PCI Realistic?
Although several smaller trials have attested to the safety and feasibility of same-day discharge (SDD) post-PCI, overnight hospitalization remains the standard of care. Several presentations at ACC.13 challenged this conventional wisdom and beg the question: "Does more hospitalization necessarily mean less risk?"Two systematic reviews presented at ACC.13 aimed to confirm the practicality of SDD across several of these smaller trials. Kimberly Brayton, MD, JD, and investigators identified 30 observational studies and 7 randomized trials evaluating same-day discharge in a range of clinical practice settings; taken together, the data revealed that SDD was at least as safe as overnight hospitalization, with a low rate of any major complications. Likewise, Olivier F. Bertrand, MD, PhD, and colleagues failed to find any benefit of overnight stay over SDD in their review of 14 studies and more than 110,000 patients. "It's not saying that same-day discharge is safe, and not saying that same-day discharge is hazardous," said co-investigator Ian Gilchrist, MD. "It's basically saying that you still can't resolve for sure whether there's a difference. It's reassuring to see that it's very difficult to tease out any difference."
Is Overnight Hospitalization Safe?The guiding question for SDD research seems to be, "Is it safe?" pointed out Dr. Gilchrist, but the question of safer than what also needs to be addressed. Despite the known risks of hospitalization, including risk of infection and medication errors, the hospital is still considered the pillar of safety when it comes to keeping PCI patients healthy. But, he posed, "What's safe about the hospital, and what are we doing for our patients by keeping them there?" Dr. Gilchrist presented data from an Australian study, which found that adverse outcomes associated with hospital stay occurred serially, increasing with each day. This included a 0.4% chance of skin breakdown, an 11% chance of infection or colonization, and 3.4% chance of adverse drug reaction or improper drug administration with 1 night's stay. Taking into account other research demonstrating the unlikelihood that a patient who has undergone relatively straightforward angioplasty and remained ischemic event–free in the first 4 hours post-procedure would experience any adverse events in the following 24 hours, it seems safe to say that safety is not an issue. Once concerns about safety of SDD are eliminated, the critical issue of patient education must be tackled. Patients kept for overnight hospitalization are not necessarily the best pupils, Dr. Gilchrist explained. After a probably sleepless overnight stay, patients (and their caregivers) are anxious to return home, and will readily agree to any and all instructions in order to expedite their "escape." "The actual retention of education materials is fairly minimal," he said. "In my opinion, the argument that you have to keep them overnight to educate them [doesn't] hold water."
So You Want to Start a Same-Day Program...According to Sunil V. Rao, MD, from Duke University Medical Center, SDD programs, which are routine in hospitals outside of the United States, may be a necessary reality for certain high-volume centers. He noted during his presentation at ACC.13: "For PCI centers that are major referral hubs, this may be a very attractive program. If you're observing your outpatient PCIs in the same beds as inpatients, it may behoove you to get these patients home—it frees up beds for other inpatients who need that level of care." For a SDD program to be effective and successful, it must address concerns in three critical domains, what Dr. Rao referred to as "the 3 Ps:" patient, procedure, and program. "The patient should be cognitively intact, show adequate social support, be medically stable, and agree that going home the same day is something they feel comfortable with," Dr. Rao explained. "The procedure, of course, should be successful, with no post-procedure bleeding and no ischemic events requiring prolonged antithrombotics. And this all has to be done in the context of a program that involves patient education." Facilitating patient exit to ensure adherence to their medication and physician instruction is perhaps the most critical obstacle for centers to tackle. Using the procedures at his center as an example, Dr. Rao outlined the outpatient practice, which focuses on patient—recovery center communication and education not only about the procedure and hemostasis, but also about the patient's disease state. "Perhaps it is time to start shortening length of stay after PCI, particularly in elective cases," Dr. Rao added, "and let the patient go back to the environment where they can actually rehabilitate quickly."
Keywords: Drug-Related Side Effects and Adverse Reactions, Referral and Consultation, Standard of Care, Inpatients, Angioplasty, Hemostasis, Patient Discharge, Caregivers, Stents, Medication Errors, Social Support, Outpatients, Australia, Hospitalization
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