Same-day discharge shown to be safe; Society guides physicians to choose correct status
Same-day discharge following a percutaneous coronary intervention (PCI) under certain conditions has gained the consensus endorsement of the Society of Cardiovascular Angiography and Interventions (SCAI).
The society recently published an update to its consensus statement on length of stay (LOS) following a PCI. Last published in 2009, the standard of care at that time was established as at least an overnight stay after any coronary artery intervention.
As techniques have evolved and rates of complications have declined, SCAI felt it was time to look at the recent literature on the safety of same-day discharge and update its recommendations.
The society defines same-day discharge as 4 to 6 hours after the completion of an elective PCI or after PCI for non-ST-elevation myocardial infarction, but only if the “three Ps” are met. The first P is the patient, who must be clinically stable at their baseline level of functioning, including all comorbid conditions. The second P is the procedure, which must have been successful, completely restoring flow with adequate hemostasis without any complication. And the third P is program, with the patient and caregivers receiving proper education, having the means to fill their prescriptions and having a follow-up already arranged. SCAI even provides sample checklists that can be used to ensure all three Ps are met.
The support for same-day discharge does not apply to patients with ST-elevation myocardial infarction (STEMI), who generally require a longer hospital stay, but in some areas those patients with uncomplicated STEMI are able to be discharged after one night in the hospital. SCAI provides data on studies and tools which can be used to risk stratify patients with STEMI to determine which are safe for early discharge.
SCAI also provided a very valuable service to all physician advisors and utilization review staff by addressing patient status for patients undergoing PCI electively, urgently, and emergently. And it actually got it right, for the most part. It correctly noted that payment for an outpatient PCI encompasses the routine recovery period, even if that includes an overnight stay. Amazingly, it even states that “terms such as extended recovery and outpatient in a bed are not the Centers for Medicare & Medicaid Services (CMS) terms; rather, they are terms developed by hospitals to classify patients for billing purposes or distinguish between certain outpatient areas.”
The society notes that observation can be ordered if the patient requires additional monitoring, referring to the “six CMS criteria for additional monitoring and care.” I was unaware that CMS established specific criteria for observation but soon realized that SCAI had taken a frequently cited list of complications (persistent nausea/vomiting, fluid/electrolyte imbalance, uncontrolled pain, dysrhythmias, excessive/uncontrolled bleeding, and psychotic behavior) and referenced that as an actual CMS criteria list. Of course, that list does contain many of the common reasons for observation, but observation may be ordered for any clinical reason where the physician determines the patient requires additional monitoring in the hospital.
The statement from the society also includes a discussion of hospital reimbursement. Wisely, SCAI chose to start with the statement that “while reimbursement should not affect discharge decisions, the financial impact of LOS decisions merits a review of the relevant policy issues.” (I’ll add that reimbursement should also not affect admission status decisions.) It goes on to explain that inpatient status is usually applied to patients staying two midnights or more, but also notes that patients with shorter stays can be admitted as inpatient if the physician’s judgment and documentation support it. It also states that inpatient reimbursement exceeds outpatient payment for the same procedure, apparently unaware of the quirk in payment which I described in a past RACmonitor article. It even provides a flow diagram to help guide cardiologists to the correct status for patients undergoing elective PCI which should be printed, laminated, and posted in every cath lab in the country.
The main point of SCAI’s discussion of reimbursement is to remind cardiologists that when the payment is fixed, any additional time spent in the hospital by the patient means added costs to the hospital. It summarizes this by stating, “Thus hospital margins, defined loosely as the difference between what the facility gets paid and what it ‘spends’ to take care of patients, may be affected by earlier or later discharge.” While this may be obvious to RACmonitor readers, physicians need to reminded of the financial consequences of their decisions, even when it involves “only” an overnight stay.
It should be noted that this consensus statement should not be viewed as establishing a new “standard of care” for patients having elective PCI and result in hospitals forcing their physicians to discharge their elective PCI patients after 4 to 6 hours of recovery. Rather, it should be used as an educational tool not only to show physicians that their professional society supports same-day discharge but also to guide hospital employees to ensure that all elements of the “program,” the third P, are in place so that physicians will feel more comfortable discharging their patients on the same day as their PCI.
The statement can be found at: https://onlinelibrary.wiley.com/doi/10.1002/ccd.27637