SCAI updates consensus on length of stay for percutaneous coronary intervention
Revised guidelines incorporating new data on discharge criteria for patients undergoing elective percutaneous coronary intervention (PCI) will allow for flexibility in length of stay while ensuring patient safety. The guidelines were published in early-view online in SCAI's official journal, Catheterization and Cardiovascular Interventions.
PCI is one of the most frequently performed medical procedures, yet there is considerable variability in the duration of hospitalization following such procedures. Traditionally, most patients undergoing elective PCI were admitted as inpatients and monitored overnight because of concerns about post-procedural complications.
Despite pressure from payers to minimize the cost of observation time, the safety of same-day and expedited discharge after PCI was not firmly established. Accordingly, in the interests of quality and patient safety, in 2009 the SCAI published an expert consensus document titled "Defining the Length of Stay (LOS) Following Percutaneous Coronary Intervention" which specified that the standard of care was an overnight stay following uncomplicated elective PCI and proposed that safeguarding patient welfare required LOS criteria be 'dictated by a level of conservatism' in the absence of definitive studies.
Since publication of the 2009 document, PCI practice has continued to evolve, and rates of post- procedural complications have declined significantly. In addition, studies have demonstrated the safety of same-day discharge in patients undergoing PCI, and that most complications occur either very early (<6 hours) or late (>24 hours) after PCI. Many patients prefer to recover from a PCI procedure at home rather than spend a night in the hospital. Same-day discharge has, therefore, become a reasonable, patient-centered approach for uncomplicated elective procedures.
The updated guidelines include new criteria to assess readiness for discharge after PCI along three lines including: procedural (successful procedure, adequate hemostasis, and without complications), patient (clinically stable, at their baseline mental status and vital signs, and with stable comorbidities), and programmatic (safe monitoring at home, appropriate guideline-directed medical therapy, compliance with PCI performance measures, and timely follow-up). Specific restrictions that previously precluded expedited discharge based on anatomic (i.e., multivessel disease, bifurcations) or patient factors (i.e., age, comorbidities) have been removed in the absence of evidence that overnight observation modifies the risk incurred.
Advances in practices and technologies have made discharge following PCI demonstrably safe when milestones of clinical stability, procedural success, and process measures have been achieved.
Ultimately, the duration of observation following PCI is a professional medical decision based on individual procedural and patient factors. The updated consensus recommendations support the reasonable judgment of physicians to allow expedited discharge following PCI without prescribing a specific period of observation for individual patients. As the leading professional organization of interventional cardiologists, the SCAI is the only organization to have published consensus recommendations on LOS after PCI, and these are expected to have a significant impact on clinical practice and health policy.
As chair of the consensus committee Arnold Seto, MD, MPA, chief of cardiology, Long Beach VA Medical Center stated, "This SCAI PCI LOS update reflects the most recent information on PCI outcomes, techniques, strategies and health care policy. The new document replaces the prior prescriptive recommendations with a new, more flexible paradigm whereby patients are ready for discharge when individualized clinical milestones are reached. These new recommendations provide for a patient-centered, evidence-based, and efficient process for patient care after both elective and nonelective PCI procedures."
More information: Takayuki Niida et al. Coronary physiological assessment combining fractional flow reserve and index of microcirculatory resistance in patients undergoing elective percutaneous coronary intervention with grey zone fractional flow reserve, Catheterization and Cardiovascular Interventions (2018). DOI: 10.1002/ccd.27570