The 2021 ACC Expert Consensus provides recommendations for the safe use of same-day discharge (SDD) following percutaneous coronary intervention (PCI) for carefully selected patients. The consensus includes checklists to help clinicians determine whether SDD is appropriate after planned or ad hoc PCI.

Same day discharge after PCI

The safe use of same-day discharge (SDD) following percutaneous coronary intervention (PCI) is still filled with uncertainty with only data from observational studies and small randomised trials supporting SDD. This 2021 ACC expert consensus addresses the uncertainty associated with SDD and provides recommendations regarding the key patient, clinical, and systems factors, such as operational resources, that should be followed to ensure the safety of SDD after PCI. The recommendations are applicable to anyone presenting for an elective PCI but are not applicable to patients presenting with ST-elevation myocardial infarction (STEMI) or non–ST-elevation myocardial infarction (NSTEMI).

SDD is defined as “a stay after a PCI procedure that does not include supervised overnight monitoring in the facility and/or hospital”. Evidence suggests that SDD is preferred by patients and data support no difference in clinical outcomes between next-day and SDD. SDD after elective PCI also allows for more efficient healthcare by optimising patient flow and resource utilisation. The consensus provides a framework in the form of checklists for considering patients for SDD after elective PCI. Here we cover the main points from the consensus.

Factors to consider before and after PCI when deciding on SDD

Pre-PCI considerations include:

• Clinical factors - Physician's input regarding whether the patient is a candidate for SDD after PCI
• Social factors - Adequate home support for the patient after SDD
• Staff/system factors - The patient is scheduled at an appropriate time for the procedure to allow for SDD later in the day

Post-PCI considerations include:

• A thorough assessment of post-procedural complications
• PCI success
• Absence of any mental status changes
• Patient’s willingness to be discharged home

Pre-discharge considerations include:

• Confirming availability of P2Y12 inhibitors
• Requirements of adequate follow-up
• Patients should be educated on monitoring the access site and be given clear instructions on an emergency number to call

Checklists for consideration of SDD after PCI

The working group developed the below checklist to help clinicians determine whether SDD is appropriate after planned or ad hoc PCI. The checklist can be used 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. The checklist to evaluate the patient's eligibility criteria is prepared considering the 3 time periods – pre-procedure, post-procedure and pre-discharge.

Components of the pre-procedure evaluation checklist

The pre-procedure checklist is drafted considering the patient clinical factors and patient social factors. The checklist comprises the following:

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 post-procedure) and discharged at a reasonable time?

Components of the post-procedure evaluation checklist

The post-procedure checklist focuses on the absence or presence of factors that indicate the patient’s clinical stability, and thus, their eligibility to be considered for SDD. The checklist comprises the following:

1. Did complications occur during the procedure?
2. Was PCI successful?
3. Is the patient experiencing any of the following post the procedure: 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)?

Components of the pre-discharge checklist

The use of a checklist prior to discharge may enhance patient satisfaction and potentially increase the number of patients who can be safely discharged home. The checklist comprises the following:

1. Confirm that the loading dose of P2Y12 inhibitor (P2Y12i) has been administered.
2. Confirm if the 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. Plans on calling the patient the day after discharge. (Name of person responsible for following up with the patient to be intimated)
6. The catheterisation lab/post-procedural staff has provided education to the 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 catheterisation lab/postprocedural staff has provided the patient with an emergency number to call.
8. The catheterisation lab/postprocedural staff has scheduled a follow-up appointment.

The panel has also included 6 clinical scenarios in the consensus document to illustrate how the checklist may be used to determine whether a patient who had a PCI should be considered for SDD or for overnight monitoring. Checklists may also be integrated into the electronic medical record and could be used to accurately measure the safety and efficacy of SDD. As per the panel, implementation of the checklists may widen the pool of patients who can be identified as candidates for safe SDD, which will lead to greater patient satisfaction and awareness as well as increased savings within facilities.