Decrease cost of inpatient stay Decrease bed diversions Improve bed utilization (Interqual Criteria) Patient Satisfaction Reduce patient costs

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2 Decrease cost of inpatient stay Decrease bed diversions Improve bed utilization (Interqual Criteria) Patient Satisfaction Reduce patient costs (family hotel, drive back to the VA for next day pick up)

3 Ø Ziakas, A (2003) retrospectively studied 811 patients in 24 hours and 1 month. 2.8% of the patients sought medical attention within the first 24 hr None hospitalized Ø Ziakas et al (2007) studied patients over and under 75 years old No differences in age No repeat admissions to the hospital Ø Chambers et al (2009) developed an expert consensus for SCAI and endorsed by the American College of Cardiology Defining length of stay and variables to consider

4 Ø STRIDE study (2008): 450 patients were monitored for short term complications while in the hospital (times of complications related to procedure end) Complications 0-6 hours 6-24 hours >24 hours Access site bleeding (minor) 11 (2.4%) None None Access site bleeding (major) None None None Post procedure infarct 8 (8.1%) None None Repeat revascularization 4 (0.9%) None None CABG/Stoke/Death/A fib None None 4 ((0.8%) Ventricular Tachycardia 1 (0.2%) None None Am Heart J 2008;156:

5 Patient meets all of the following criteria YES NO Elective PCI Successful PCI-defined as <50% residual stenosis, TIMI 3, no residual stenosis LVEF > 30% by an imaging modality Radial Access Controlled blood pressure <180/100 Stent length < 28 mm in 1 vessel and without bifurcation placement Single vessel PCI Sheath size < 6F Resides, 60 minutes from a PCI center Patient has a caregiver (reliable person) at home Reliable transportation Creatinine < 1.5 mg/dl and/or egfr > 60 ml/min INR < 2.0 Procedures completed by 1300 Patients have reliable telephone communication system

6 Patients excluded with any of the following factors YES NO Patient has neurological changes intra or post PCI Patient requires prolonged anticoagulation therapy post PCI Inpatient Status Recent STEMI or NSTEMI (<72 hours) Compromised coronary artery side branch Chest pain post procedure Thrombus in a coronary vessel Any resuscitation (pre, intra, post procedure) PCI without stent Received IIbIIIa inhibitors or low molecular weight heparin Thrombolytic therapy within 48 hours of the PCI CHF episode within 3 months prior to PCI Access site complications (hematoma, bleeding) Unreliable patient for follow-up and/or educational teaching

7 Process for Same Day PCI Patient Selection Prep RN Phone number verified Transportation verified Prep RN Home help verified Address verified (60 miles) Prep RN Creatinine/eGFR evaluated INR evaluated

8 Prep RN LVEF obtained Outpt status verified-elective Prep RN Recent STEMI/NSTEMI CHF episode (3 months) Prep RN Thrombolytic therapy (48 hr) Received Lovenox (12 hr)

9 Lab RN Neurological changes Prolonged post anticoagulation Lab RN Compromised side branch Thrombus in coronary vessel Lab RN Single vessel PCI PCI without stent

10 Lab RN Lab RN Lab RN Sheath size < 6F Stent length < 28 mm No bifurcation location Radial access Successful PCI

11 Post RN Chest pain post procedure Any resuscitation event Post RN Access site complications Unreliable patient education Post RN Controlled BP <180/100 Procedure completed by1300

12 RESPONSIBILITIES OF STAFF Cath Lab Nursing Staff Informing SDS of Same Day PCI DC Same Day Recovery (Aldrete Score > 9) or baseline Immediate post ECG

13 Cath Lab Nursing Staff Providing written instruction and ensuring understanding Scheduling follow-up appointment Contacting Discharge Pharmacy for Plavix and ASA delivery to SDS

14 Cardiology Fellow PCI order sets including Troponin, CK- MB, CBC, 12 lead ECG at 4 hours Medication prescription for outpatient ASA and Plavix ordered Discharge Instruction and ensuring understanding

15 Cardiology Fellow No changes in baseline ECG No chest pain Review all ECGs and labs prior to discharge Ensuring no post procedure complications occurred

16 Responsible for filling Same Day PCI prescriptions in a timely manner Pharmacy Hand delivering Plavix and ASA to patient Responsible for medication education

17 Same Day Nursing Staff Responsible for monitoring patient s status and updating MD as needed Responsible for 4 hour labs and ECG acquisition Responsible for discharge assessments and patient s understanding of instructions

18 Monday-Thursday Saturday Cath Lab staff contact the patient and place a post procedure telephone note in CPRS Same Day Surgery staff contact the patient and place a post procedure telephone note in CPRS

19 Ensure all check and balances are completed for each area Develop strict guidelines or protocols to follow Place Same Day PCI patients to a single unit Work to ensure a stable and reliable staff in that single unit Clearly identify points that would defer the discharge Track outcomes Saturday follow-up is necessary