Improving efficiencies and patient outcomes in the cath lab can go hand in hand. Strategies that reduce length of stay, risk and waste often lead to better care and sometimes cost savings. But upfront investments, change in workflow and reimbursement constraints can pose a challenge to their uptake.
Nudged by necessity
Interventional cardiologists at Mount Sinai Hospital in New York City recognized that they faced a resource crunch. The problem was beds, or lack thereof, for patients treated in their cardiac catheterization laboratory. “We knew that if it was a really busy day, then there probably was not going to be enough beds for an overnight stay for all these patients,” says Michael Kim, MD, former director of the cardiac care unit at Mount Sinai.
The physicians also knew that many of their elective PCI cases would not develop complications, with patients sleeping through the night before being discharged. As far back as the mid-1990s, cardiologists had shown they could discharge low-risk patients safely within the same day of an elective PCI using a transradial approach (Am Coll Cardiol 1997;29:323–327). And so in 2001, Mount Sinai began testing the water, sending home a few uncomplicated cases the day of the procedure. By 2011, their same-day discharge numbers had grown to 2,000 for the year.
“We were way ahead of the game,” says Kim, who now serves as the cath lab director at North Shore University Hospital in Manhasset, N.Y. The Society of Cardiovascular Angiography and Interventions and the American College of Cardiology wouldn’t publish a consensus statement setting standards for short-stay PCI until eight years later (Catheter Cardiovasc Interv 2009;73:847-858).
Today same-day PCI strategies are recognized as both efficient and beneficial to patients. “When people stay in the hospital too long, you increase the list of medical errors and inappropriate testing because in the hospital [staff] order more labs, whether they need them or not,” says Ehtisham Mahmud, MD, chief of cardiovascular medicine, co-director of the Sulpizio Cardiovascular Center and director of interventional cardiology and the cardiac cath lab at the University of California San Diego Health System in La Jolla. “They don’t necessarily think through the reasons for all those labs.”
Mahmud’s group is one of many that have rolled out same-day PCI programs in the past few years as evidence and protocols have emerged. While early demonstrations showed same-day discharge after transradial PCI was safe, Kim and his colleagues at Mount Sinai provided reassurance that same-day PCI using a transfemoral approach in a diverse patient population didn’t compromise patient care, either. In an analysis of 30-day outcomes for 2,000 consecutive same-day elective PCIs between 2003 and 2008—99.5 percent done transfemorally—eight patients experienced major adverse events, another 14 had bleeding complications and one a pseudoaneurysm (J Am Cardiol Cardiovasc Interv 2010;3:851-858). The average length of stay barely topped eight hours.
“The reality is most patients prefer to go home, given the option,” says Kim, who continued offering same-day discharge at North Shore when he came on board in 2013. “At Sinai, we would offer patients to go home at midnight and nine out of 10 said ‘OK’ vs. having to spend a night in the hospital.”
Some cardiologists aren’t comfortable discharging patients from eight to 23 hours after a PCI, but Sunil V. Rao, MD, of the Duke University Medical Center in Durham, N.C., challenged an audience at the 2013 Transcatheter Cardiovascular Therapeutics meeting in San Francisco to question that position. Using CathPCI Registry data, Rao and colleagues found same-day PCI was rare among Medicare beneficiaries but that it had similar rates of vascular complication, two-day and 30-day mortality and two-day and 30-day rehospitalization as an overnight stay (JAMA 2011;306:1461-1467).
“The most important thing here is to do what you think is best for the patient,” he said at a session on same-day discharge. “But I also would encourage all of you to go back to your practice and look at the numbers of patients you are keeping overnight simply because that is traditionally what you have always done vs. the number if patients you were really worried about.”
Hospital administration also may need to be persuaded that the benefits outweigh the costs. Similar to Mount Sinai, Mahmud made a case that a short-stay program would free