Changes in reimbursement have put pressure on health care facilities to shift more elective percutaneous coronary interventions (PCIs) to “same-day” outpatient procedures. This marked shift could place patients at risk if they are sent home prematurely, and has left physicians without clear guidance as to when such early discharge is appropriate. To help guide physicians in making these decisions, the Society for Cardiovascular Angiography and Interventions (SCAI) has published an expert consensus statement outlining the variables physicians should consider when deciding how long patients should stay in the hospital following an uncomplicated elective PCI. The document, titled “Defining the Length of Stay Following Percutaneous Coronary Intervention,” was published online today in Catheterization and Cardiovascular Interventions (CCI; e-publication ahead of print, June 2009, vol. 73, issue 7) and has been endorsed by the American College of Cardiology Foundation.
Elective PCI refers to patients who have stable symptoms but abnormalities in testing that indicate the need for further evaluation by coronary angiography. Depending on the results of the angiogram, some will go on to have a PCI procedure.While short length of stay following an uncomplicated PCI is a key benefit of the procedure, the current standard in the United States is for the patient to remain overnight in a health care facility.
“Because of continued breakthroughs in interventional cardiology, few patients today have to stay in the hospital for two or more days after angioplasty as they did in the past, but it’s not always clear which patients should be kept overnight or admitted to the hospital, and which patients can safely return home the same day,” said Carl Tommaso, MD, FSCAI,associate professor of medicine at Rush University Medical School, and director of the cardiac catheterization laboratory at Skokie Hospital, North Shore University Health Systems in Chicago, and a senior author of the consensus statement. “The goal of this document is to guide physicians making decisions for follow-up care after an elective PCI. Ultimately, the physician should make the decision based on the patient’s specific condition and the criteria outlined in this paper.”
According to the consensus paper, some patients may safely go home the same day as their PCI, but other patients should be placed in one of three settings determined by the treating physician:
- Observation: Patients in this category require a longer period of observation but less than 24 hours, such as an overnight stay to monitor for potential complications or lab tests. Observation is also appropriate for patients who do not have adequate at-home care or access to emergency medical services.
- Extended Observation: These patients require more than 24 hours of observation and care, usually as a result of accompanying non-cardiac conditions, but not a prolonged hospital admission.
- In-Patient Admission: Patients who should be admitted include those who experienced complications during PCI, those who require further revascularization and those with significant co-morbidities.
The consensus paper provides a decision matrix to guide physicians in determining the appropriate length of stay following PCI.
“Each patient situation is unique and we have to consider all the variables when determining follow-up care, including whether a patient has someone at home to help him or her,” said Gregory J. Dehmer, MD, FSCAI, professor of medicine at Texas A&M University College of Medicine, director of the Cardiology Division at Scott & White Healthcare in Temple, TX, and co-author of the statement. “We need to have the flexibility to watch patients overnight or longer to ensure appropriate care for every one of our patients.”
"Interventional cardiologists support optimal care for each patient balanced against responsible measures to reduce unnecessary medical costs. This paper from SCAI is designed to provide guidance to help physicians make the most appropriate decisions on follow-up care after PCI," said SCAI President-Elect Steven R. Bailey, MD, FSCAI, chair of the Division of Cardiology, professor of medicine and radiology, and Janey Briscoe Distinguished Chair at the University of Texas Health Sciences Center at San Antonio. "Decisions about when to discharge a patient should never be solely about cost or reimbursement, but about exercising the best-informed medical judgment for each patient."