Clinical studies have shown that in appropriately selected patients, same-day discharge following PCI is as safe as routine overnight observation. Survey data tell us that patients prefer same-day discharge as well. Yet it’s still rare for patients to—as I like to say—get home in time for dinner after their PCI.
When we looked at proprietary data from our Crimson technology platform, we found that the average length of stay (ALOS) for outpatient PCI at most hospitals precludes same-day discharge. In fact, the median program’s ALOS is 27 hours. It’s not until you consider the top 10% of hospitals (based on ALOS) before you find same-day discharge as a routine practice. Those progressive centers have gotten ALOS down to just eight hours.
Physician resistance a key barrier to adoption
Conservatively, we estimate that most programs have the potential to discharge 30-40% of their outpatient PCI cases same-day. But several real or perceived hurdles stand in the way of making this happen. According to Cardiovascular Roundtable members, physician resistance is the biggest barrier. Root causes include safety concerns, inertia of ingrained practice patterns, and the learning curve associated with new approaches.
The first step in overcoming this resistance is to demonstrate the safety and efficacy of same-day discharge using data. Providing physicians with published reports helps, but it’s more effective to share with them outcomes data from their own peer group, including procedure success rates, complications, and readmissions that compare inpatient and outpatient PCI.
To further encourage practice change, another member, St. Joseph Mercy, added eligibility screening for same-day discharge of PCI to its list of physician practice incentive metrics. Screening represents 8% of their total at-risk pay opportunity. Now nearly 100% of patients are screened, and 16% of elective patients go home the day of their procedure.
Low physician adoption of transradial access may also contribute to anemic same-day discharge rates. While transradial PCI isn’t a prerequisite for quick discharge, it is a significant enabler.
Set clear criteria at every stage of care
Developing patient selection criteria and dedicated care pathways is essential for boosting same-day procedures. The benefits are intuitive and include easier patient identification, care standardization, and enhanced staff confidence with new practice patterns. Still, only about half of Roundtable members have same-day discharge criteria for CV interventions (PCI, ICD implants, etc).
What’s the key insight from progressive centers? Three-part eligibility criteria. It’s not enough to just set initial eligibility criteria, because a patient’s status may change in the course of their care. Piedmont Healthcare demonstrates this lesson. Their cath lab team assesses patients before, during, and after the procedure using specific measures to ensure patients meet eligibility requirements for same-day discharge. And they’ve established clear accountability for who is responsible for each assessment. Their results are impressive, including a 13% increase in same-day discharge within one year of implementation and a 12 hour reduction in average length of stay for PCI.
Create a supportive operational infrastructure
Even the most robust clinical criteria can’t enable same-day discharge when operational barriers persist. Too often uncoordinated scheduling and ineffective care setting and staffing configurations work against efficient discharge.
The cath lab schedule must be configured to prioritize early morning slots for patients identified as same-day discharge candidates. While it’s an obvious point, it’s not standard practice. To optimize this strategy, patents should be screened beforehand, and in the absence of robust pre-screening, we recommend frontloading radial access patients. For most hospitals, 11 a.m. or 12 p.m. is the cutoff for having a reasonable chance at discharging patients without an overnight stay. But with discipline, most labs can accommodate the majority of their low-risk, same-day discharge candidates.
Efforts to discharge patients efficiently will be thwarted if the recovery process isn’t fine-tuned. Patients tagged for same-day discharge should not follow the standard recovery protocol. Ideally they will be placed in an interventional recovery unit near the cath lab and staffed by a team focused on short-stay CV care. The team should function on an assembly line model, supporting sheath pulling, ambulation, patient education, etc.