Same-day Discharge Patients Research Articles

Safety and Efficacy of Same-Day Discharge Following Elective Percutaneous Coronary Intervention, Including Evaluation of Next Day Troponin T Levels

As patients are increasingly undergoing elective percutaneous coronary intervention (PCI) with same-day discharge (SDD), and as post-PCI troponin T (TnT) elevations are associated with increased rates of death/myocardial infarction (MI) following elective PCI, we examined late outcomes with respect to post-PCI TnT elevations in patients undergoing SDD. We studied 303 patients (mean age 62±9years, 89% male) who underwent elective-PCI between October 2007 and September 2012, of whom 149 had SDD and 154 stayed overnight (ON) who were age-and sex-matched. Eligibility for SDD excluded patients with: multi-vessel PCI, proximal LAD lesions, chronic total occlusions, side branch occlusions, or access site complications. Femoral access rates were 72% and 96% among SDD and ON patients respectively. Post-PCI, SDD patients left at 4.40[4.13-5.30]hours, and ON patients left at 23.44[21.50-25.41]hours (p<0.001). Overall 8.45% met the 2012 universal MI definition. No patients were re-hospitalised within 48hours. At 30-days, unplanned cardiac re-hospitalisation rates were 3.4% and 0.7% among SDD and ON patients (p=0.118); the only event was MI in an SDD patient. At 16[9-32] months, rates of death, MI, target vessel revascularisation, stroke, were 1.3%,1.3%,2.7% and 1% respectively; the composite rate was 6%(6.1% SDD; 6% ON; p=0.965). Late death/MI rates among patients with, and without, post-PCI TnT levels≥5xURL were 3.4% and 2.8% respectively (p=0.588). SDD following elective PCI among low risk patients appears to be safe and ≥5 fold post-PCI TnT elevations did not appear to confer incremental short and long term risk. A larger cohort is required to confirm this observation.

Day-case versus inpatient laparoscopic fundoplication: outcomes, quality of life and cost-analysis

Day-case laparoscopic Nissen-Rossetti fundoplication (LF) has been demonstrated to be safe in small, prospective cohorts. The purpose of the study was to compare postoperative course, functional results, quality of life, and healthcare costs in patients undergoing LF in a day-case surgical unit with same-day discharge and patients undergoing LF as an inpatient. All consecutive patients in our department who underwent a primary LF for symptomatic uncomplicated gastroesophageal reflux disease from 2004 to 2011 were entered into a prospective database (n = 292). From 101 same-day discharge patients (day-case group), control inpatient procedures were randomly matched by age, gender, body mass index, American Society of Anesthesiologists classification, and presence of a hiatal hernia (inpatient group, n = 101). No postoperative deaths occurred and postoperative morbidity occurred in 9.4% of patients. When comparing day-case and inpatient groups, postoperative morbidity rates were 9.9 vs. 8.9% (p = 0.81) with median hospital stays and readmission rates of 1 vs. 4 days (p < 0.001) and 7.9 vs. 0% (p < 0.001), respectively. Gastrointestinal Quality of Life Index was significantly enhanced due to surgery (p < 0.001) and comparable in the two groups. Estimated direct healthcare costs per patient were 2,248 euros in the day-case group vs. 6,569 euros in the inpatient group (p < 0.001), equivalent to a cost saving of 3,921 euros. Day-case and inpatient approaches after LF give similar results in terms of postoperative mortality and morbidity, functional outcomes and quality of life, with a substantial cost saving in favor of a day-case procedure.

Feasibility of Early Discharge After Implantable Cardioverter‐Defibrillator Procedures

Registry data demonstrate considerably low complication rates after implantable cardioverter-defibrillator (ICD) procedures for primary prevention of sudden death. Yet standard of care includes postimplant overnight in-hospital observation that may levy substantial unnecessary financial burden on health care systems. In appropriate patients, discharge soon after implant could translate into significant cost savings, if such practice does not result in complications. We applied a simple clinical algorithm to assess feasibility of discharge on the same day of ICD implantation in patients at low risk for procedural complications. We prospectively randomized primary prevention ICD candidates at low risk for complications (not pacing-dependent or requiring bridging heparin anticoagulation) to next-day discharge with overnight in-hospital observation, or same-day discharge with remote monitoring for 24 hours after ICD implant. Implants were performed via cephalic vein access, and randomization occurred after 4-hours clinical observation and device interrogation. All patients were followed for a minimum of 6 weeks to assess acute procedural complications. 71 patients comprised the study cohort (mean age 62, 79% male) after 3 were excluded. The most common indication for ICD implant was ischemic cardiomyopathy with ejection fraction ≤35%. Device data obtained through 24-hour remote monitoring was comparable to 4-hour postimplant parameters in same-day discharge patients. No acute complications occurred in same-day discharge patients; 1 next-day discharge patient developed pneumothorax. ICD implantation with same-day discharge is reasonable in patients at low risk for complications. Remote monitoring can be useful in indicating lead-parameter stability during the immediate postoperative period.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis

Background/PurposeThis study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. MethodsAfter institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. ResultsLaparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). ConclusionRoutine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Prevalence and Outcomes of Same-Day Discharge After Elective Percutaneous Coronary Intervention Among Older Patients

Patients undergoing elective percutaneous coronary intervention (PCI) are generally observed overnight in the hospital. The association between same-day discharge of older patients and death or readmission is unclear. To evaluate the prevalence and outcomes of same-day discharge among older patients undergoing elective PCI in the United States. Multicenter cohort study. Data were from 107,018 patients 65 years or older undergoing elective PCI procedures at 903 sites participating in the CathPCI Registry between November 2004 and December 2008 and were linked with Medicare Part A claims. Patients were divided into 2 groups based on their length of stay after PCI: same-day discharge or overnight stay. Death or rehospitalization occurring within 2 days and by 30 days after PCI. The prevalence of same-day discharge was 1.25% (95% CI, 1.19%-1.32%; n = 1339 patients) with significant variation across facilities. Patient characteristics were similar between the 2 groups, although same-day discharge patients underwent shorter procedures with less multivessel intervention. There were no significant differences in the rates of death or rehospitalization at 2 days (same-day discharge, 0.37% [95% CI, 0.16%-0.87%] vs overnight stay, 0.50% [95% CI, 0.46%-0.54%]; P = .51) or at 30 days (same-day discharge, 9.63% [95% CI, 8.17%-11.33%] vs overnight stay, 9.70% [95% CI, 9.52%-9.88%]; P = .94). Among patients with adverse outcomes, the median time to death or rehospitalization did not differ significantly between the groups (same-day discharge, 13 days [interquartile range, 7.0-21.0] vs overnight stay, 14 days [interquartile range, 7.0-21.0]; P = .96). After adjustment for patient and procedure characteristics, same-day discharge was not significantly associated with 30-day death or rehospitalization (adjusted odds ratio, 0.95 [95% CI, 0.78-1.16]). Among selected low-risk Medicare patients undergoing elective PCI, same-day discharge is rarely implemented but is not associated with death or rehospitalization compared with overnight observation.

Randomized Trial Comparing Same-Day Discharge With Overnight Hospital Stay After Percutaneous Coronary Intervention

Percutaneous coronary intervention (PCI) in a day-case setting might reduce logistic constraints on hospital resources, but data on safety are limited. We evaluated the safety and feasibility of same-day discharge after PCI. Eight hundred consecutive patients scheduled for elective PCI by femoral approach were randomized to same-day discharge or overnight hospital stay. Four hours after PCI, patients were triaged as suitable for early discharge or not. Suitable patients were discharged immediately or kept overnight, according to randomization. Patients with an indication for extended hospital stay were not discharged regardless of randomization. Primary end points were death, myocardial infarction, coronary artery bypass graft surgery, repeat PCI, or puncture-related complications occurring within 24 hours after PCI. A total of 403 patients were assigned to same-day discharge, of whom 77 (19%) were identified for extended observation; 397 patients were assigned to overnight stay, of whom 85 (21%) were identified for extended observation. Among all patients, the composite primary end point occurred in 9 (2.2%) same-day discharge patients and in 17 (4.2%) overnight stay patients (risk difference, -0.020; 95% CI, -0.045 to -0.004; P for noninferiority <0.0001). Among patients deemed suitable for early discharge, the composite end point occurred in 1 of 326 (0.3%) same-day discharge patients and 2 of 312 (0.6%) overnight-stay patients (risk difference, -0.003; 95% CI, -0.014 to 0.007; P for noninferiority <0.0001). The last 3 events were related to puncture site. Same-day discharge after elective PCI is feasible and safe in the majority (80%) of patients selected for day-case PCI. Same-day discharge does not lead to additional complications compared with overnight stay.

Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study

Background: Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. Methods: A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. Results: Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. Conclusions: Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission. (Gastrointest Endosc 1999;49:580-6.)