Same-day Discharge Following Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis of Randomised Controlled Trials.

Same-day discharge after elective percutaneous coronary intervention: A single center experience

The 30-day readmission rate of same-day discharge protocol following catheter ablation for atrial fibrillation: a propensity score-matched analysis from National Readmission Database.

In this issue of Circulation , Bertrand et al1 report the results of the Early Discharge after Transradial Stenting of Coronary Arteries (EASY) Study. After receiving a standard bolus of abciximab and undergoing a successful and uncomplicated transradial stent placement, 1005 patients were randomized to a traditional strategy with overnight hospitalization or early discharge after 4 to 6 hours. All patients received aspirin, clopidogrel, and a bolus dose of abciximab before their procedure. Those in the traditional strategy group also received a 12-hour abciximab infusion, whereas those in the early discharge group did not. The goal of the EASY study was to show that stent implantation by the radial approach with only a bolus of abciximab and then early discharge was not inferior to the traditional strategy in terms of effectiveness and safety. The primary composite end point was the 30-day incidence of death, any myocardial infarction, unplanned revascularization, major bleeding, repeat hospitalization, access-site complications, or severe thrombocytopenia. On the basis of their data, the authors concluded that the abbreviated abciximab therapy with same-day discharge was clinically not inferior to the traditional strategy after uncomplicated stent placement. Article p 2636 With healthcare costs increasing, strategies to limit expenditures are popular and deserve careful examination. Accepted cardiology practice has moved toward dramatically shortened hospital stays for diagnostic coronary angiography and percutaneous coronary intervention (PCI) as well as many other procedures. The present study suggests that many patients who undergo PCI could be managed safely as outpatients. Substantial accomplishments in the practice of PCI have resulted in the excellent success and safety of the procedure we now observe, but are we ready for routine outpatient PCI? The use of radial artery access has been well described in the literature. Despite studies demonstrating the feasibility, safety, and acceptance by patients of this …

Over the past 30 years, dramatic improvements have been achieved in the safety of percutaneous coronary intervention (PCI) procedures, despite the increasing complexity of clinical and anatomic conditions treated. The need for emergent bypass surgery has declined from 8% in 1990 to far less than 1% in the current era, and the rate of vascular complications has declined dramatically as techniques have improved and procedural experience has increased. Given the remarkable current periprocedural safety profile of elective coronary intervention, has the time come for us to consider whether outpatient PCI can be safely performed? In this issue of Circulation , investigators from the Academic Medical Center of the University of Amsterdam investigated this question as part of the Elective PCI in Outpatient Study (EPOS).1 Article p 2299 The study by Heyde and colleagues randomly assigned 800 consecutive, elective, outpatient, planned PCI patients to a strategy of either same-day discharge or routine care that included an overnight observation in the hospital. The patients and providers were blinded to the assignment until after evaluation according to predefined criteria for those patients who required additional observation or treatment. All patients eligible for same-day discharge, regardless of assignment, were then strictly observed for 4 hours and then underwent a rigorous triage evaluation to determine if same-day discharge would be appropriate. At that time, those patients who were randomized to the same-day discharge group were discharged, whereas the patients randomized to the overnight hospitalization group were kept in-hospital for observation. The investigators found that 20% of patients in both disposition arms developed one of the predefined exclusions for same-day discharge. Of the ≈80% of patients suitable for same-day discharge, none suffered a cardiac event within 24 hours after PCI, and only 3 patients suffered a vascular complication, with no differences observed in the 2 …

Catheter ablation (CA) is a common treatment for atrial fibrillation (AF). This study evaluated outcomes of same day discharge (SDD) versus overnight stay (ONS) among AF patients undergoing outpatient CA. The Optum SES Clinformatics Extended Data Mart database was used to identify patients ≥18 years of age undergoing outpatient CA for AF (2016-2020). Eligible patients were indexed to the date of first CA and classified into SDD and ONS groups based on the length of service. A 1:3 propensity score matching was used to create comparable SDD:ONS samples. The primary safety outcome was CA-related complications within 30 days of index procedure. The primary efficacy outcome was AF recurrence within 1 year. Cox proportional hazards models were estimated for outcome comparison. In the postmatch 30-day cohort for safety evaluation, there were 6600 patients (1660 [25.2%] SDD; 4940 [74.8%] ONS), with a mean age of 66.6 years. There was no significant difference in the 30-day composite rate of postablation complications (4.7% [78/1660] vs. 3.8% [187/4940]; p = 0.100) and 1-year composite rate of AF recurrence (14.3% [142/996] vs. 14.5% [430/2972]; p = 0.705) between the SDD and ONS groups. This study demonstrated that SDD following CA to treat patients with AF is safe, with low rates of postablation complications and AF recurrence, which were comparable to rates in patients with an ONS after CA.

Thirty-day readmission rate of same-day discharge protocol after left atrial appendage occlusion: A propensity score-matched analysis from the National Readmission Database.

Same day discharge after laparoscopic cholecystectomy in children

B-PO04-144 SAFETY AND FEASIBILITY OF SAME DAY DISCHARGE AFTER PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION

Economic Impact And SafetY of Same-Day Discharge Following Percutaneous Coronary Intervention: A Tertiary-Care Centre Experience From Northern India (EASY-SDD)

Q Are there evidence-based guidelines or best practices related to same-day discharge of a patient who had a percutaneous coronary intervention?A Cynthia Webner, DNP, CCNS, ACNPC-AG, CCRN-CMC, CHFN, replies:Since Dr Andreas Grüntzig1 and his colleagues in 1979 published the result of their experience with the first 50 patients to undergo percutaneous transluminal coronary angioplasty in Zurich, Switzerland, technology has advanced. The incidence of percutaneous coronary interventions (PCIs) outdistances the number of patients undergoing coronary artery bypass grafting by 3 to 1.2,3 The volume of inpatient PCI procedures reaches nearly 1 million annually in the United States2 and the number of hospitals in the United States providing PCI continues to increase.3,4 Advancements in technology, operator skill, increased procedural success, and improved safety, including low postprocedural complication rates, contribute to more patients being considered for same-day discharge after an uncomplicated elective PCI. There are reports of same-day PCI discharges since the late 1990s. However, many patients continue to stay overnight following elective procedures.5 Fiscal responsibility encourages a same-day discharge strategy resulting in substantial cost savings.5,6 Resistance to same-day discharge remains because of concern for patient safety.The most recent PCI guidelines from the American College of Cardiology do not address same-day discharge after PCI.7 However, the Society for Cardiovascular Angiography and Interventions (SCAI), with support from the American College of Cardiology, published a consensus document in 2009 outlining the clinical decision-making process regarding the length of stay for the PCI patient. Postprocedural complications, including abrupt vessel closure, access-site complications, and management of comorbid conditions, are some of the top concerns for patient safety. Regarding same-day discharge, the SCAI recommends the facility consider locating this population in 1 unit with a consistent staff who are proficient in procedure follow-up, expected complications, and treatment of those complications. The staff should also be proficient in providing patient education, which should include recognition of and response to procedural complications, an understanding of the importance of dual antiplatelet agents, risk factor modification strategies, and physician follow-up. Assessment of outcome data is essential with the development of a same-day PCI discharge program.8On the basis of multiple clinical studies assessing outcomes related to same-day discharge, the SCAI provides a classification scheme for the management of patients after PCI. This classification system can provide direction when considering same-day discharge. The classification scheme considers high-risk patient features, including advanced age, decreased renal function, reduced left ventricular ejection fraction, female sex, diabetes mellitus, and more complex coronary lesions. The scheme identifies 6 categories of criteria to assist in the decision to include or exclude patients from the same-day discharge plan: (1) clinical criteria, (2) comorbidity considerations, (3) anatomic coronary complexity, (4) procedural complexity, (5) complications, and (6) other criteria, with consideration for social aspects.8Since the publication of these criteria, further research has demonstrated good outcomes with same-day discharge in patients with both femoral and radial access.5,9–11 Jabara and colleagues12 evaluated 450 patients who had undergone transradial PCI and demonstrated that all complications occurred either within 0 to 6 hours of the procedure or more than 24 hours after the procedure. Subherwal and colleagues9 evaluated more than 1 million patients who underwent PCI from 2005 through 2009 to determine complication rates including bleeding. During this time there was a nearly 20% reduction in post-PCI bleeding. Elective PCI had the lowest rate of bleeding, decreasing from 1.4% to 1.1%. Non–ST-segment elevation myocardial infarction bleeding rates also dropped from 2.3% to 1.8%, with no significant change noted in patients with ST-segment elevation myocardial infarction. One of the likely reasons for decreased access-site bleeding rates in patients undergoing PCI as reported by this study is the noticeable change in antithrombotic strategy, with an increased procedural use of bivalirudin alone (from 17% to 30%) and a decreased procedural use of heparin and bivalirudin in combination (from 41% to 28%).9On the basis of studies published through 2015, Shroff and colleagues13 recommend liberalization of some of the criteria put forth by the SCAI for same-day PCI discharge. The authors cite increased patient satisfaction, increased bed availability, and substantial cost savings as benefits to same-day discharge.13 As same-day post-PCI discharges increase, clinical experts agree that a successful same-day discharge strategy should consider the patient, the procedure, and the program.13,14 Formal programs that consider patient-related factors such as social support, the ability to comply with recommendations (including reporting of adverse events), understanding of dual antiplatelet therapy, and the willingness and ability to comply with follow-up should be established. Current evidence suggests that same-day PCI discharge can be safe and beneficial for the patient and organization in select patients. However, formal structures and processes of care should be well established for a same-day PCI discharge program to be successful.15

Same-day discharge (SDD) after catheter ablation of atrial fibrillation (AF) may address the growing socio-economic health burden of the increasing demand for interventional AF therapies. This systematic review and meta-analysis analyses the current evidence on clinical outcomes in SDD after AF ablation compared with overnight stay (ONS). A systematic search of the PubMed database was performed. Pre-defined endpoints were complications at short-term (24-96 h) and 30-day post-discharge, re-hospitalization, and/or emergency room (ER) visits at 30-day post-discharge, and 30-day mortality. Twenty-four studies (154 716 patients) were included. Random-effects models were applied for meta-analyses of pooled endpoint prevalence in the SDD cohort and for comparison between SDD and ONS cohorts. Pooled estimates for complications after SDD were low both for short-term [2%; 95% confidence interval (CI): 1-5%; I2: 89%) and 30-day follow-up (2%; 95% CI: 1-4%; I2: 91%). There was no significant difference in complications rates between SDD and ONS [short-term: risk ratio (RR): 1.62; 95% CI: 0.52-5.01; I2: 37%; 30 days: RR: 0.65; 95% CI: 0.42-1.00; I2: 95%). Pooled rates of re-hospitalization/ER visits after SDD were 4% (95% CI: 1-10%; I2: 96%) with no statistically significant difference between SDD and ONS (RR: 0.86; 95% CI: 0.58-1.27; I2: 61%). Pooled 30-day mortality was low after SDD (0%; 95% CI: 0-1%; I2: 33%). All studies were subject to a relevant risk of bias, mainly due to study design. In this meta-analysis including a large contemporary cohort, SDD after AF ablation was associated with low prevalence of post-discharge complications, re-hospitalizations/ER visits and mortality, and a similar risk compared with ONS. Due to limited quality of current evidence, further prospective, randomized trials are needed to confirm safety of SDD and define patient- and procedure-related prerequisites for successful and safe SDD strategies.

Same versus next day discharge after elective transradial PCI: The RAdial SAme Day DischArge after PCI trial. (The RASADDA-PCI trial).

Barriers to Early Discharge after Elective Percutaneous Coronary Intervention (BED PCI): A Single-Center Study

In the COVID-19 era, there has been increasing interest in same-day discharge (SDD) after total joint arthroplasty (TJA). However, patient perception of SDD is not well reported. We sought to understand patients' perceptions and preferences of postoperative care by surveying patients who have completed both an overnight stay (ONS) and an SDD after TJA. We emailed survey links to 67 patients who previously underwent either 2 total hip arthroplasties (THAs) or 2 total knee arthroplasties (TKAs). Fifty-two patients (78%) responded to the survey. Thirty-four (65%) patients underwent staged, bilateral TKAs, and 18 (35%) patients underwent staged, bilateral THAs. Overall, 63% of patients preferred their SDD, 12% had no preference, and 25% preferred their ONS, with no difference in preference between TKA and THA groups. Those who preferred their SDD reported being more comfortable at home. Those who preferred their ONS felt their pain and concerns were better addressed. No differences were found in comfort, sleep quality, appetite, burden on family, return to function, feelings of being discharged too soon, overall experience, 30-day emergency department (ED) visits, or readmissions within 30 days between patients' SDD and ONS. There was a small statistically significant difference between patients' perception of safety between SDD and ONS. Our survey found that most patients reported a preference for SDD after TJA over ONS. Although there was a small difference in patient perception of safety, there were no differences in return to the ED or readmissions after SDD and ONS.

Background: Stable patients (pts) undergoing an uncomplicated elective percutaneous coronary intervention (PCI) typically stay in the hospital overnight after their procedure. Many studies suggest that in carefully selected pts, discharge within hours after the PCI appears to be safe. There are no studies, however, comparing the economic impact of same day versus next day discharge. Objective: We sought to evaluate the safety and economic impact of same day discharge after an uncomplicated PCI compared with those after an overnight observation stay.. Methods: We performed a retrospective review of pts who underwent elective PCI and were discharged the same day vs. next day (from observation status) at Geisinger Medical Center between 1/1/2008 to 9/15/2013. The same-day discharge program for selected pts (“outpatient PCI”) was initiated in 2010. Guidelines for same day discharge included negative troponins at 4 hours; readiness for discharge before 8:00 pm; freedom from CHF; LVEF >40%; live within <60 miles; no impediment to obtaining immediate medical attention after discharge if needed; BMI <40, and no severe aortic regurgitation. Thirty-day outcomes were analyzed. Results: A total of 1164 elective PCI pts were identified; 280 (24%) were discharged the same day (Group 1) and 884 (76%) stayed overnight (Group 2), by physician preference. The radial route was used in 47% of pts, and increased over time. No same day discharge pts were readmitted within 24 hours. At 30 days, there were no differences between Group 1 vs. 2 in frequency of access site complications (0% vs. 0.01%), peri-procedural MI (0 % vs. 0.006%), urgent care/ED visit or readmission (0.05% vs. 0.08%) (P=NS all comparisons). Stent thrombosis and death did not occur in either group in the first 24 hr post PCI. The average charges were $67,471 for pts discharged the same day, 17% less than the $81,175 for those who spent a night being observed in the hospital (P < 0.0001). Conclusions: Same day discharge after an uncomplicated PCI and 4 hour observation period was safe and resulted in significantly reduced charges.