It's time to begin offering same-day discharge to your electrophysiology (EP) patients.
There are plenty of good strategic reasons to make the change: You're facing financial challenges and tightening budgets. You're laboring under mandates to improve efficiency and throughput. You need to save bed space for higher-acuity patients.
But the best reason to move to same-day discharge is simply this: In most cases, it's safe and effective—and it's what your patients want.
We've previously explored why EP should be a focus for cardiovascular (CV) leaders amid the Covid-19 epidemic. This blog post will explore how improved efficiency and throughput of EP procedures can further your cardiovascular service line's goals clinically, financially, and strategically.
What is 'same-day discharge'—and why can it be challenging to achieve?
First, let's clear up our terminology.
Some CV programs use the phrase "same-day discharge," or SDD, to refer to any discharge within 24 hours. But we're setting a higher bar: We're defining SDD to mean discharging the patients on the same calendar day as the procedure, or alternatively at a length of stay of 12 hours or fewer.
CV programs increasingly are achieving same-day discharge for percutaneous coronary intervention (PCI) patients, but in our experience, it's rarer for EP patients to be discharged so rapidly. Many programs just don't yet have the physician support, consistent protocols to guide patient selection, and needed infrastructure.
In particular, physicians may worry about the safety and feasibility of same-day discharge for EP patients—so it's worth doing a deep dive into the clinical evidence.
Is same-day discharge safe for EP patients?
Leading CV programs have for years discharged their EP patients on the day of admission, and a significant body of evidence shows the practice can be safe and effective.
Several studies have demonstrated that same-day discharge after atrial fibrillation (AF) ablation is feasible with the use of a standardized protocol and is not associated with higher hospital readmission or complication rates after discharge. In fact, it may reduce the risk of hospital-acquired infections by limiting the time in the hospital.
For instance, a study published in June in the Journal of the American College of Cardiology: Clinical Electrophysiology looked at more than 3,000 patients who underwent AF ablation from 2010 to 2014. Of those patients, 79% were discharged on the same day—and the study found similar complication rates for the SDD group as for patients kept overnight. The authors concluded, "Same-day discharge after AF ablation is feasible in the majority of patients with use of a standardized protocol. This approach was not associated with higher hospital readmission or complication rates after discharge."
The study did raise one potential caution: In a subgroup analysis of 420 patients, those discharged the same day faced a higher rate of ED visits after their procedure, with the most common cause being AF/arrhythmia. This suggests that institutions implementing SDD should put into place support systems to reduce and manage ED visits, such as providing dedicated AF navigators, a nurse hotline, standardized follow-up phone scripting when checking on patients post-discharge, and so on.
Similarly, another study published in 2020 in Heart, Lung and Circulation discharged 128 of 448 ablation patients home the same day with no significant difference in complication rate (3.3%) compared to patients that spent the night. Procedural success rates were also similar between groups.
It's important to note that not all EP patients are appropriate candidates for SDD. Evaluation criteria should include age, comorbidities, preference on being discharged early, caregiving support, and level of ablation complexity, among others. Some institutions also place restrictions around the distance from the patient's home to the hospital.
Is same-day discharge cost-effective for CV programs?
Evidence shows that SDD can generate significant cost savings—not only by eliminating the costs associated with an overnight stay, but also by providing the opportunity for a higher-acuity patient to fill the vacated space in an overnight bed.
For example, a 2013 study published in Pacing and Clinical Electrophysiology found savings of almost $5,600 per patient receiving an implantable cardioverter defibrillator (ICD):
Additionally, reimbursement rates continue to rise for EP procedures, like ablations. So not only can programs save costs by discharging patients early when appropriate, the resulting profit margins from these services can impact the broader CV program's financial performance.
Is same-day discharge the right strategic decision for you?
Especially amid the Covid-19 epidemic, it's critical for CV service lines to have strategies in place that allow them to flex their capacity for the unknown.
If you put in place the infrastructure to support same-day discharge, you may have the flexibility to save space for higher-acuity patients. You could also free care teams from needing to spend their mornings discharging ablation patients, letting them focus on other patients who may need their attention more. And if you're already offering same-day discharge for PCI patients, you can achieve greater scale and efficiency by offering same-day discharge for EP patients too.
Of course, perhaps the biggest factor to consider is patient satisfaction. A 2018 study of PCI patients found that 99% of patients reporting feeling "extremely satisfied" with same-day discharge. It just makes sense that your patients want to get home as soon as possible—especially at a time when many worry that an extended hospital stay could expose them to Covid-19. Additionally, it is well-established that excess length of stay in the hospital can increase the risk of hospital-acquired infections (HAIs). As one example, a recent study in Nature concluded that an extended hospitalization is associated with an increased risk of HAIs after cardiac surgery. Another study specifically on catheter ablation for AF discovered that length of stay was significantly associated with development of a urinary tract infection (UTI) (OR 1.07 per hospitalized day above mean, p=0.0009).