Chris’s Corner: Drive-By STEMI Management
On service last month, I admitted a patient with an inferior STEMI using the "Admit to Observation" coding, indicating that she would spend less than 23 hours in the hospital. You might be thinking that decision seems odd for a STEMI... Could that really be true? Don't STEMI patients stay in the CCU for at least that long, followed by a few days stay in the cardiac step-down unit, and then go home? Some might criticize the rapid in-and-out STEMI management, and accuse us of offering "drive-by" service for our STEMI patients. But, could this speedy customer service be a good thing for our patients?
Well, in my opinion, I believe it is a good thing—for the right patient. Patient selection is key. Ideally, a patient in whom we can get rapid reperfusion with primary PCI, limit the infarct size, and preserve left ventricular function will have a very low risk of mortality and can safely be discharged. At this point, all the treatments have been given (along with dual antiplatelet therapy, a beta-blocker, ACE inhibitor, and high-dose statin), so there really is no need to keep the patient in the hospital any longer.
An earlier discharge lets patients begin their rehabilitation faster, and lets the medical system save on the cost of managing patients' illnesses. There are downsides, however, including less time for direct teaching by the nursing staff and physicians and perhaps less time for the seriousness of the event to "sink in" to the patient's mind. The extended hospital stay offers time for patients to reflect on the fact that they had a very serious illness and need to make some changes in their lifestyle.
Picking the Right Patient
This would not be the approach for all patients, obviously. Anyone with a larger MI and some hemodynamic instability would need more monitoring, drug treatment, and titration of doses. But for patients with lower-risk, smaller MIs, rapid STEMI management could be great. I recall using this approach with a 70-year-old patient who was admitted after an anterior MI: he was rapidly sent to the cath lab, underwent a successful PCI, was rock solid, and was sent home the next day. It's really amazing.
At the other end of the ACS spectrum (those patients with chest pain, but it is unclear if it is ACS), we try to assign a shorter-than-23-hour observation time in the hospital. These chest pain patients are often given a diagnosis of a "Rule Out MI"—which is not a diagnosis, but a plan—and are admitted to the observation unit in the emergency department. If that's full, or if the ED physician was too worried about the patient, they are admitted to the cardiology service.
Most of these patients are actually having a "Maalox Moment," as I jokingly refer to it with the house staff. It's actually supported by good data, though: the leading cause of non-cardiac chest pain in an emergency department population is GI reflux.
Oddly, for these patients at low risk for ACS, we often fail to discharge them in less than 23 hours, usually because of scheduling of the stress tests, but sometimes transportation home or other non-medical issues. Isn't it ironic: we can get a STEMI patient in and out in less than 24 hours, but we struggle to stick to that time frame for non-cardiac chest pain patients?
You might find that using this shorter length of stay in clinical practice is at odds with the recommendations in textbooks that we have all read. Some of the texts on my bookshelf endorse a typical stay of 5 to 6 days. While some acknowledge that particular patients can be discharged more expeditiously, I could not find any mention of coding STEMI as "admit to observation." It seems that clinical practice evolves rapidly, but our textbooks lag a bit. Hopefully I won't be writing next year about outpatient primary PCI! That might be too much.
Christopher P. Cannon, MD, is a professor of medicine at Harvard Medical School in Boston, Massachusetts. He is also the Editor in Chief of CardioSource Science and Quality.
Keywords: Patient Selection, Transportation, Emergency Service, Hospital, Hemodynamics, Length of Stay
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