Where are the old (and not so good) days when a patient with myocardial infarction was staying in hospital bed for a week?
During busy morning rounding post our STEMI night call we increasingly see our last night proximal LAD STEMI patient anxiously pacing the halls with a tiny dot on the wrists asking to be sent home the same day, as he/she has other, important matters to attend. That simply does not give doctors, nurses, dietitians, rehab experts enough time for education regarding the disease, medications, risk factors, and behavioral modifications.
Patients increasingly regard their heart attacks as “small bumps on the road” in their lives, not a direct threat to life, frequently not following medical community recommendations regarding medications, rehab, and life style modifications. For us, it is a challenge to be able to explain to the patient during a short hospital stay that in fact he or she was on the brink of death, and another 15 minutes of delay in care may have resulted in 180 degrees different outcome.
Nowadays most patients with a STEMI and successful revascularization go home within 48 hours and if they are motivated they resume their golf schedule within a week (or OR schedule if they happen to work as MDs).
Novel anticoagulants, antiplatelets, statins, 60-90 minutes DTB (door to balloon) times, 5 or 6 French sheeths for stent delivery and foremost radial access for coronary interventions coupled with “gentle discharge pressures” from hospital systems reduced most STEMI hospital stays to 2 days in most cases.
Elective cardiovascular procedures including coronary, peripheral, EP and venous are also increasingly done as outpatient visits. Across the country over the last 5 years we see increased utilization of radial artery access for procedures, which are becoming the standard of care, with the patient being preloaded with 2 antiplatelet agents several days before. In those cases it is safe to discharge the patient home the same day, and outcome data supports this approach.
A new trend in endovascular procedures includes radial artery access not only for coronary but also for peripheral interventions with the same day discharge. At the present day we are limited in this approach by devices which do not have yet in many cases long enough sheeths to reach below the knee arteries from radial access. Industry is working fast to bridge this gap.
Advances in safety of endovascular procedures and changes in reimbursement prompted a country-wide mushrooming of Outpatient Based Labs (OBLs), which allow treatment of PAD and venous conditions with the same day discharge. They seem to be gaining popularity fast, yet they typically do not have the full complement of devices to treat the patients the same way we would do it in the hospital, including lack of reimbursement for drug coated balloons (DCBs), which became the standard of care for treatment of SFA and popliteal disease in most cases.
It should be looked upon and seen if the outcomes of PAD patients treated in outpatient setting will match outcomes that can be achieved in hospital settings.
Short, or zero overnight hospital stay cardiovascular procedures are quickly becoming the standard of care in the US. Who would want a nurse to wake you up at 4.30am to get your vitals, and stick you with needles after all?
The impact of this trend on patients’ outcomes remains to be studied.
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