Same-day discharge after percutaneous coronary procedures—Consensus statement of the working group of interventional cardiology (AGIK) of the Austrian Society of Cardiology

Following the ACC methodology for creating expert consensus decision pathways [12], this consensus document was developed as a draft outline within the working group and circulated among a task force of the AGIK for peer review. Individual practice guidelines from all individual interventional outpatient clinics were integrated. The final document was once again circulated for organizational review and approval from the Austrian Society of Cardiology.

This position paper is based on three consensus documents on SDD PCI published by the SCAI [4, 5, 13] and one from the ACC [3]. Furthermore, a systematic literature review and meta-analysis was performed by the Austrian Society of Cardiology focusing on SDD after radial access PCI [14].

Reports on PCIs as daycare procedures in selected patients have been published since the late 1980s [15], remarkably in an era where femoral access was still the procedural standard and balloon angioplasty alone the dominant treatment option for coronary artery stenoses. Since then many centers have adopted radial access PCI as the standard treatment option for elective patients and SDD PCI numbers are steadily increasing in the USA and across Europe:

In their 2021 cross-sectional analysis of the American CathPCI Registry Bradley et al. studied the frequency of patients undergoing elective PCI discharged on the day of procedure [16]. From a total of 819,091 elective PCIs in 1716 hospitals, the survey showed a rapid increase of SDD PCI from 4.5% in 2009 to 28.6% in 2017, a trend that was even more prominent in radial access procedures (increase from 9.9% to 39.7%) compared to femoral access PCI (increase from 4.3% to 19.5%). Dividing the study duration into three time intervals (2009–2011, 2012–2014, 2015–2017), the authors also demonstrated a substantial increase in radial access PCI among SDD (21.8%, 43.4% and 58.3%, respectively) and overnight stay patients (7.8%, 20.1% and 32.6%, respectively) [16]. Among SDD PCI procedures, the percentage of proximal LAD and high risk or type C lesion PCIs also significantly increased over the study period. On the other hand, the authors show a large hospital-level variation of SDD frequencies with 25% of the sites studied discharging < 10% of their patients on the day of PCI despite radial access [16].

Similar trends were published in a Canadian study showing data from 35,972 procedures from 17 clinics in and around Ontario, Canada, from 2008 to 2015 [17]. During the study period the total rate of SDD PCI increased from 17% in 2008 to 45% in 2015; however, as in the previous study, a substantial interhospital variation was detected, including 17 clinics with 0–17% SDD PCI. Indicators of high SDD PCI rates were (1) university clinics and university-affiliated teaching hospitals (40.1% vs. 10.7%), (2) presence of onsite cardiac surgery departments (34.9% vs. 9.4%), and (3) centers with > 50% radial access use (42.8% vs. 25.9%) [17].

A 10-year single-center study from France (from 2007 to 2016) showed a comparable increase in SDD PCI procedures from 14% in 2008 to 32% in 2015 [18]. Comparing SDD vs. overnight stay patients, the authors found that in the SDD cohort radial access was used more often, two-vessel CAD was less frequent, and the average number of stents implanted per procedure was lower [18]. The most common reason for overnight admission was the wish to monitor patients in the absence of any complications.

It is worth noting that the increase in SDD PCI procedures runs parallel with a general temporal trend of patients referred to the catheterization laboratory being older, having more comorbidities and a higher calculated risk score for coronary interventions [2]. In a retrospective longitudinal analysis from the Veteran’s Affairs Clinical Assessment, Reporting and Tracking Program data from 2009 to 2015 Waldo et al. detected a significant increase in the proportion of DA and PCI patients who had a high Framingham risk score. The hazard ratio (HR) for mortality, however, remained constant over time, with a nonsignificant decrease among those undergoing intervention (HR 0.983; 95% confidence interval, CI 0.967–1.000). Similar to the trends in SDD procedures cited above, the authors found a steep increase in radial access from 5% to 32% [2].

A substantial number of Austrian cardiology centers have introduced daycare beds or daycare departments in order to offer a specific scope of procedures on a SDD basis. Generally, DA, PCI, right heart catheterization, cardioversion, loop recorder implant, pacemaker/automatic internal cardioverter defibrillator device replacement as well as administration of intravenous therapy, such as iron infusion, diuretic or antibiotic therapies are being offered as SDD procedures. Depending on the inventories and local environments of the clinics, there are individual policies considering the scope and extent of SDD services. In all centers, local guidelines exist detailing conditions when to switch treatment of a patient back to OS and spare bed capacities are reserved for this purpose.

Currently SDD PCPs are offered by 77% of all cardiology centers in Austria. Of these clinics 40% are running the ambulatory procedures via dedicated outpatient departments and 55% have integrated outpatient beds into regular wards (5% missing data). Fixed protocols or checklists for accepting or rejecting patients for ambulatory procedures have been established in 85% of Austrian cardiology centers. While 77% of clinics offer DA as SDD procedures, only 35% are performing PCI in an outpatient setting. There is some heterogeneity of local protocols with single-stent PCI considered feasible for SDD in all centers performing PCI in an ambulatory setting, while bifurcations, multiple stent and multivessel (MV) PCI are switched to OS in the majority of centers. The volume of SDD cases varies from 2 per week up to 6 per day, whereas the coronavirus disease 2019 (COVID-19) pandemic with subsequent shortages on routine wards has led to an increase in the volume of SDD cases in almost all clinics.

Different clinics have established various local arrangements to integrate a daycare facility into existing cardiology departments. There are two dominant forms of implementation: (1) SDD beds integrated into regular wards where the same doctors, nurses and service staff treat and monitor outpatients, and (2) dedicated outpatient clinics, sometimes shared between different departments (e.g., cardiology combined with gastroenterology, surgery or dermatology), where specific outpatient doctors and nurses are on duty. One benefit of the first form of outpatient clinics is greater flexibility in discharge times, especially considering the waiting period with wound compression after PCI (sometimes up to 6 h). As staff are present on the regular wards virtually 24 h/7 days per week, discharge can take place without any limitation. On the other hand, SDD capacities would be equally compromised in cases of staff shortages or bed reallocation due to COVID-19. Independent outpatient departments (implementation 2) are somewhat more limited in operating hours, on the other hand the general appearance as a non-ward department is preferred by some patients. The staff are also focused on outpatients only and free from many duties connected with generally more immobile patients on regular wards, which could improve the general treatment atmosphere.

As stated above, the Austrian Society of Cardiology has performed a systematic literature review and meta-analysis to substantiate its practice recommendations [14]. In short, four large meta-analyses have published outcome data for SDD PCI [19‐22], summarizing 38,785 patients with SDD and 256,049 patients staying overnight. All four meta-analyses are consistent in demonstrating no added risk of SDD practice assessed by MACE at 24 h and/or 30 days.

It could be argued that in all trials including RCTs patients deemed suitable for SDD represent a selected patient population, generally being younger, with a lower burden of chronic medical conditions, less severe degree of CAD and residence not far from the interventional clinic; however, it is the very same selection process that is unanimously being recommended by current advisories to identify potential patients suitable for SDD PCP [3, 4]. It was never intended to offer SDD PCPs to all patients with an indication for coronary angiography or PCI. Conversely, the application of current SDD selection criteria has been shown to be effective: A comparison between randomized and non-randomized (excluded) patients from the RCT by Bertrand et al. [23] showed that the rate of MACE (death, MI, TVR) in patients excluded from randomization was significantly higher at 30 days (10.2% vs. 1.6%), 6 months (17.5% vs. 5.6%), and 12 months (24.5% vs. 9%) as compared with randomized patients [13, 23].

Finally, it should be pointed out that none of the observational studies, RCTs or meta-analyses discussed above featured a protocol where only DA was considered suitable for SDD or where PCI/stent implantation was by default an exclusion criterion for SDD. The safety and outcome data extracted exclusively represent PCI on a SDD basis.

With growing experience of SDD PCPs and especially PCIs, some centers have extended the SDD concept to more challenging PCI indications, once again highlighting the robust safety profile of this treatment approach [24‐29]. We have reviewed the evidence base for SDD PCI in higher-risk settings. This includes complex PCI, elderly patients (age > 75 years), rotational atherectomy, chronic total occlusion PCI, and left main PCI. Briefly, currently available data from a multitude of trials shows no additional risk for these challenging settings. It must be acknowledged, however, that a large number of trials are retrospective analyses from registries and that a significant degree of heterogeneity exists considering the frequency of higher-risk PCIs on a SDD basis.

Patient preference should be taken into account when scheduling invasive procedures. There is a well-documented patient preference towards radial access for PCP, which leads to less discomfort, less frequent hematomas and better quality of life postprocedure [30, 31].

Across different countries, different study settings and decades of interventional experience SDD after PCP has been shown to be the preferred treatment mode as opposed to OS [6‐8, 32‐36], satisfying another clear patient preference for short hospital stay, earlier and easier ambulation.

Numerous international studies on cost efficacy of SDD departments have demonstrated a potential for significant cost savings when performing PCPs in an ambulatory setting, while maintaining the existing catheterization laboratory inventories and staff at the center [35‐38].

Data from Austria confirm that for the individual cardiology departments, the setup of an interventional outpatient clinic into an existing infrastructure does not involve large investments. A calculation from the University Clinic Innsbruck has shown that after implementation of a cardiology outpatient clinic, estimated annual treatment costs could be reduced by about 560,000 €, the largest component being cost for personnel (University Clinic for Internal Medicine III, Medical University of Innsbruck; unpublished data), consistent with reductions in fixed hospital costs reported before [37].

All SDD PCPs should be performed by clinics and medical centers with a high annual workload of coronary procedures. Consistent with the 2020 SCAI recommendations for ambulatory surgical centers, we recommend that only operators with an expertise in interventional cardiology, a personal experience beyond a total of 500 procedures and an annual workload of > 50 procedures should be performing PCPs in the outpatient setting [4]. A specialized hospital program or SOP for SDD PCPs should be in place including secretaries, nurses and catheterization laboratory personnel, defining the relevant steps from assessment of referrals, scheduling of appointments for outpatient evaluation, daycare admission, cathlab procedure, postprocedure patient care, discharge criteria checklist, and clinical follow-up protocol.

At any time from referral to discharge, including the patient’s own condition as well as observations by all levels of personnel, the goal of SDD should be critically re-evaluated.

An experienced colleague should be available at all times to assist in the preprocedural and postprocedural care and to manage discharge formalities for interventional daycare patients. If these tasks are simply added to the list of responsibilities for the interventionalists in the catheterization laboratory, a lack of patient supervision and delays in the discharge process, especially in high volume interventional centers, will be the consequence.

In the outpatient clinic either beds or lounge chairs enabling the patients to relax and enjoy some privacy should be present. While live telemetry of ECG and oxygen saturation as in intermediate care units is not considered necessary, nurses should be present at all times during opening hours and there should be a standard protocol detailing the frequency for preinterventional and postinterventional surveillance. Emergency medical equipment for intubation/resuscitation, pericardiocentesis, and at least one echocardiography device and one ECG printer should be present in the outpatient clinic to facilitate swift diagnostics and intervention if a patient’s condition should deteriorate. If the outpatient beds are included into the inventory of a regular ward, the facilities and technical outfit of the normal ward are sufficient.

The plan to perform a coronary procedure in an outpatient setting should be discussed with the patient as early as possible and personal concerns and questions should be addressed in an effort of shared decision making.

Relevant social and medical patient characteristics preventing the planned procedure from being performed in a SDD setting are summarized as a checklist in Table 2. One of the critical criteria at this time is the presence of a partner or relative who could assist in transporting the patient to the clinic and back home for the preclinical outpatient assessment and on the day of the procedure. Furthermore, advanced age or serious medical conditions should be taken into consideration. These include decompensated heart failure with LVEF < 30%, severe kidney disease and uncontrolled diabetes mellitus. If clinically stable and compensated, however, these chronic conditions do not exclude SDD PCP.

Specific early slots in the catheterization laboratory program are required for SDD patients, so that the mandatory period of 3–6 h radial compression and clinical observation can be completed without compromising discharge in the afternoon/evening.

All SDD coronary procedures should only be performed by experienced operators with an expertise in non-femoral puncture techniques including radial or ulnar access. Radial access facilitates early mobilization and is associated with lower mortality, fewer adverse cardiovascular events, and bleeding complications [51, 52]. Furthermore, there is a clear patient preference of radial versus femoral access PCPs [8, 30] (see above). The interventional team should be experienced in treating challenging radial anatomies and potential access site complications. If the access site needs to be switched to brachial or femoral due to vascular calcifications or complications during radial puncture, the patient should be scheduled for OS.

As highlighted by the 2021 ACC [3] and the 2018 SCAI [5] expert consensus documents, the clinical condition of the patient during and postprocedure has a greater impact on the final decision on SDD or the length of stay than individual features of the intervention. As summarized in our literature review [14], there is a wide range of RCTs and observational studies supporting the safety of SDD post-PCI even in challenging settings. Consistent with the ACC and SCAI recommendations, we consider SDD postelective PCI feasible and safe, including multivessel DES implantation, bifurcations, proximal/ostial lesions, and successful CTO. If complications or periprocedural adverse events summarized as a checklist in Table 3 occur, SDD is no longer safely possible and the clinical management should be altered to OS, potentially with constant surveillance and treatment depending on the nature of the adverse event. It should be emphasized that the scope of interventions offered within a daycare clinic should reflect the individual interventional center’s expertise and scope of interventions.

A large observational study on SDD PCI from 2012 showed excellent safety data in a broad range of patients outside the SCAI/ACC recommendations [13] at that time (2009). These results highlight that any guidelines or position statements should acknowledge further trends in clinical practice standards with developing clinical evidence on safety.

Consistent with elective DAs and PCIs in OS patients, postprocedural ECGs can be considered, cardiac enzyme tests are not necessary in the SDD setting, except in the presence of periprocedural complications, persistent symptoms indicative of myocardial ischemia or cardiac decompensation. In this context it should be noted that two large retrospective studies with cohorts > 5000 patients have established that while a preinterventional elevation in serum Trop-T correlates with an adverse outcome, in the absence of periprocedural myocardial infarction a postinterventional rise in Trop‑T does not offer any prognostic significance beyond the preinterventional value [53, 54]. In the SDD setting, an age-matched study of 149 SDD versus 154 OS patients showed that post-PCI Trop‑T levels > 5 × upper refererence level (URL) did not indicate any incremental short-term or long-term risk [55]. There is no need for bed rest or confinement to a single room in the daycare clinic. Nevertheless, a standardized monitoring protocol should be in place during the 3–6 h of compression bandage. The puncture site and blood pressure should be checked and recorded at regular intervals (e.g. 1×/h).

In the presence of adverse clinical events, summarized in Table 4, adequate diagnostic measures including BP testing, trans-thoracic echocardiography (TTE), ECG and laboratory tests must be taken. In cases of adverse outcome, the clinical strategy must be changed from SDD to OS and this explained to the patient. This also involves unforeseen social patient factors, e.g., if the personal contact providing transfer from the clinic and home support is no longer available or if the patient may no longer feel comfortable with the concept of SDD.

The final decision to discharge the patient on the same day should finally be made in agreement with the patient and by nurses, catheterization laboratory personnel, interventionalists and an experienced physician at the ward.

If the outcome of the PCP is successful and postinterventional monitoring was uneventful without changes in pre-existing medical conditions, discharge can be scheduled after removal of the radial pressure bandage. The compression time should be 3 h after DA and 4–6 h after PCI. An experienced doctor, ideally the interventionalist, should inspect the patient’s condition and the puncture site after removal of the pressure bandage and give the final decision of discharge.

A structured discharge process with a checklist containing all necessary steps is recommended. An example of a discharge checklist is provided in Table 5. The patient needs to be instructed on changes in the medical treatment, especially on the importance of DAPT in case of PCI with DES implantation. After PCI, the patient should leave the daycare clinic with a prescription of DAPT to provide a gapless concomitant therapy poststent implant. Ideally, a telephone follow-up call is arranged for the next working day in order to verify the patient’s well-being after discharge.

Consistent with the ACC 2021 expert consensus [3], a clinical follow-up (FU) of SDD PCP patients should be considered in order to collect data on perceived quality of care, potential complications post discharge and to reinforce DAPT medication adherence. This could be done via telephone call on the day post PCP, without the patient having to visit the outpatient department again. It has been documented in prospective studies that DAPT adherence post-SDD PCI is high (87–95%) [8, 56]. In the latter study, nurse-led post-SDD PCI telephone interviews had no influence on P2Y12 inhibitor adherence (telephone 95% vs. control 93%, p = 0.627) [56]; however, the authors did find that routine follow-up calls significantly reduced the frequency of unscheduled patient readmittance (8% vs. 16%, p = 0.048), as well as self-initiated contacts to general practitioners (29% vs. 42%, p = 0.02) [56]. A study from the Netherlands formally assessed the preferred mode of FU post-SDD treatment in 1797 patients treated from 2008 to 2012 [57]. Remarkably, the majority of patients (69.9%) preferred a FU by mail questionnaire, while only a smaller portion of patients preferred a telephone call (13.4%) or email (12.7%; p < 0.001) [57]. It is open to speculation, if this trend has changed in the meantime with a more dominant role of mobile telephones and email access even for older patients. While the AGIK does not mandate strict clinical follow-ups as they bind substantial resources, it must be pointed out that due to the novelty of the concept of SDD and the substantial impact it has on the post-PCI FU process, individual FU data from Austria would be valuable. Alternatively, patient follow-up and aftercare could be performed by resident physicians if close cooperation with the team of the catheter lab is guaranteed. The more critical an individual interventional center views the concept of SDD, the more rigorously it should be collecting clinical FU data.