Same-Day Discharge After PCI: ACC Expert Consensus Decision Pathway

The American College of Cardiology has published in the Journal of the American College of Cardiology an Expert Consensus Decision Pathway (ECDP) to provide guidance on same-day discharge (SDD) of patients who have undergone percutaneous coronary intervention (PCI).¹

As data indicating that overnight monitoring can be safely avoided in some patients who have undergone PCI stems from retrospective studies and only small randomized trials, there is still uncertainty regarding SDD in those patients “This ECDP aims to address this uncertainty and provide guidance about the key patient, clinical, and systems factors, such as operational resources, that must be in place to ensure the safety of SDD after PCI,” noted the ACC writing committee.

“The impetus for SDD for PCI reflects not only patient preference and satisfaction, but also safety,” the committee stated. “In terms of major adverse cardiovascular events, meta-analyses have found no difference between same- and next-day discharge following PCI.”

In addition, many facilities are unable to meet the admission demands of their emergency departments, so that SDD after PCI may be associated with economic benefits.

The ECDP applies to adult patients who present for elective PCI, not to those with ST-elevation myocardial infarction (STEMI) or non–ST-elevation myocardial infarction (NSTEMI). In the ECDP, patients who present with STEMI or NSTEMI should be hospitalized ≥1 night for postprocedural monitoring based on presentation, clinical features, and procedure-related considerations.

“The format of this ECDP, currently a checklist, may be adapted to fit the needs and processes of individual institutions,” stated the writing committee. “This document encourages shared decision-making with the patient about whether to pursue SDD after PCI.”

The ECDP endorses the 2015 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions update on primary PCI for patients with STEMI.² PCI is considered elective, if it is “performed on an outpatient basis without significant risk [for] infarction or death,” In the National Cardiovascular Data Registry. SDD after PCI is defined as a stay after a PCI procedure that does not include supervised overnight monitoring in the facility and/or hospital.

“The patient will stay for routine monitoring of variable duration after the procedure, based on factors such as access site and procedural characteristics, but will typically be discharged within 12 hours after arrival at the facility or catheterization laboratory (some monitoring periods may be shorter or longer),” noted the committee.

PCI is defined as successful by the National Cardiovascular Data Registry if <50% poststenosis, TIMI 3 flow, and 20% or greater reduction from prestenosis to poststenosis are achieved.

The working group developed the below checklist to help clinicians determine whether SDD is appropriate after planned or ad hoc PCI.

Preprocedure Evaluation

1. Is the patient experiencing STEMI or NSTEMI?
2. Does any member of the care team feel for any other reason that the patient is not a candidate for same-day discharge?
3. Does the patient have adequate caregiver support?
4. Can the patient or caregiver reach 911, if necessary?
5. Is the patient willing to be discharged the same day (shared decision-making)?
6. Is the patient scheduled early enough in the day so that he or she can be observed for a sufficient amount of time (4-6 hours postprocedure) and discharged at a reasonable time?

Postprocedure Evaluation

1. Did complications occur during the procedure?
2. Was PCI successful?
3. Is the patient experiencing any of the following postprocedure? Stroke, bleed, vascular complications, allergic reaction, unresolved and/or severe chest pain, acute heart failure, persistent ischemic electrocardiogram changes, dysrhythmia, or any other unforeseen complications.
4. Is there an exacerbation of an underlying disease (eg, heart failure, high blood pressure, diabetes, chronic obstructive pulmonary disease flare)?
5. Is the patient’s mental status the same as baseline presentation?
6. Is the patient willing to be discharged the same day (shared decision-making)?

Predischarge Checklist

1. Confirm that loading dose of P2Y12 inhibitor (P2Y₁₂i) has been administered.
2. Confirm patient has received prescriptions for at least 30 days of P2Y₁₂i.
3. Confirm prescription for aspirin and statin.
4. Confirm referral to cardiac rehab.
5. (Name of person responsible for following up with patient) plans on calling patient the day after discharge.
6. The catheterization lab/postprocedural staff has provided education to patient on how to monitor access site (in-person training, handouts, videos, etc) and the importance of taking adequate dual antiplatelet therapy (DAPT) as prescribed and the specific risks of premature discontinuation.
7. The catheterization lab/postprocedural staff has provided the patient with an emergency number to call.
8. The catheterization lab/postprocedural staff has scheduled a follow-up appointment.

“The checklist is intended to document both initial patient eligibility before the procedure as well as the absence of subsequent exclusionary criteria during the peri- and post-PCI periods,” noted the writing committee. “Ideally, patients suitable for SDD should be identified prior to the procedure and be informed as early as possible of the goal for SDD.”

The writing committee emphasized that the checklist should not be considered prescriptive but instead a guide to help with decision-making. In addition, although the checklist may be initiated before PCI, the group recommended that a final decision about SDD should only be made after all checklist items have been answered.

Implementing safe and effective SDD relies on the identification of specific team members responsible for its delivery. “The SDD checklist should be presented as a tool that addresses multiple facets of the patient care pathway, ensuring safe patient recovery, education, and follow-up. Ideally, the process of completing the checklist enhances communication between staff and physicians on patient-specific concerns,” noted the pathway authors.

A DAPT regimen involving a P2Y₁₂i must be at the forefront of the checklist and the electronic health record should confirm prescriptions for aspirin and statin therapy, as well as a referral to cardiac rehabilitation.

The ACC writing committee also emphasized the need for administrative support for SDD and the SDD checklist.

“It is the belief of the working group that implementing this checklist, and thus likely widening the pool of patients who can be identified as candidates for safe SDD, will lead to greater patient satisfaction and awareness as well as increased savings within facilities,” stated the writing committee. “Implementation of this checklist also provides institutions with an opportunity to carry out quality evaluations as data from the checklist can be used to inform the evolution of future checklists and protocols in SDD for PCI.”

This ECDP was approved by the American College of Cardiology Clinical Policy Approval Committee.

Disclosures: Some of the writing committee members reported affiliations with medical device companies. Please see the original reference for a full list of disclosures.

References

1. Rao SV, Vidovich MI, Gilchrist IC, et al. 2021 ACC expert consensus decision pathway on same-day discharge after percutaneous coronary intervention: A report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol.
2. Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol. 2016;67(10):1235-1250.