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The Beat Webinar Series - Episode 4 - Same Day Dis ...
The Beat Episode 4: Same Day Discharge, EP Procedu ...
The Beat Episode 4: Same Day Discharge, EP Procedures
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Hello everyone, welcome to this webinar series, it's an educational program from the Heart Rhythm Society, the BEAT. My name is Prash Sanders, I'm from the University of Adelaide and the Royal Adelaide Hospital in Australia. And we have an incredible session on same day discharge after EP procedures. We have presentations and people experienced in this area. We're in an era when healthcare hospitals are under significant pressure and there's greater amount of pressure to send people home on the same day. Here we're going to present and discuss how, who, when and the protocols associated with that. I'd like to introduce to you Mike Lloyd, who's from a professor of medicine at the Emory University Hospital to introduce the moderators for this session. Thanks Prash. This is a really important topic and who better to guide us through this than our advanced practice providers. And so I'd like to introduce first Julie Shea, who is a nurse practitioner and research nurse at the Cardiac Arrhythmia Service at the Brigham in Boston. Julie has been a veritable force for the Heart Rhythm Society as far as volunteerism and service, board of trustees, planning committee. She's chair of a LEAP program, which is really important for our allied team and serves as a correspondent for Heart Rhythm TV. She's well-published and ready to help us get through this difficult, but very timely topic. And also we have Deepthi Varghese. Dee is an acute care certified nurse practitioner who currently serves as an EP nurse practitioner at Northside here in my neck of the woods in Atlanta. She's been instrumental in creating a lot of programs and is thus very well qualified to talk on this same day discharge topic. And when she's not getting access and placing catheters and putting temp wires in, she's been instrumental in helping not only our committee, but serving the Heart Rhythm Society as well. So welcome Julie and Dee and thank you. Thanks so much, Mike. I really appreciate that kind of words from you. I have the honor and the privilege of introducing our distinguished speakers this evening. First I'd like to introduce Lauren Rousseau. Lauren is one of our senior physician assistants in cardiac electrophysiology at Brigham and Women's Hospital. Besides her clinical care, she focuses on professional education, clinical skills and research initiatives at the Brigham. She is also an active member of the Heart Rhythm Society. She has her cardiac device specialist certification from IBRI and she is most notably has received two distinguished awards from the Heart Rhythm Society. One was for a high-scoring abstract for women in EP in 2019. And then again, she won high-scoring abstract for the Allied Professionals in 2021. Lauren is also currently participating in the LEAP program, the class of 2023. For those of you who don't know, that is the Leadership and Education for Allied Professionals. And she was one of 20 to make this LEAP group. So I'm really excited to hear Lauren's presentation this evening. As well, I have the honor to also introduce another one of my colleagues, Dr. Bruce Copeland, who is a clinical cardiac electrophysiologist at Brigham and Women's Hospital. He's also an assistant professor of medicine at Harvard Medical School. And Dr. Copeland's research focuses on the treatment of complex arrhythmia. He focuses on the quality of care with regard to arrhythmia management, catheter ablation, and implantable cardiovertebrate defibrillators. He's the author of over 100 peer-reviewed publications and his practice focuses on innovation in the management of cardiac arrhythmias. And this has landed Dr. Copeland as one of America's top doctors by Castle Conley. So welcome, Lauren, welcome Dr. Copeland to our webinar this evening, and we look forward to hearing your presentations. It is my pleasure to introduce our excellent panelists, Dr. Dheeraj Gupta and Dr. Saroj Kiani. Professor Gupta has been a very high volume operator in interventional electrophysiology since 2007 and has earned particular repute for his interventional management skills for atrial fibrillation, the most common heart rhythm disorder. He is one of the largest volume implanters for left atrial appendage occluder devices in the UK, and he proctors cardiologists extensively in the UK, USA, and Europe in this technique. Professor Gupta has been awarded NHS Local Clinical Excellence Awards in 2010, 2014, and 2015, the National Bronze Clinical Excellence Award in 2016, and the National Silver Clinical Excellence Award in 2021. Professor Gupta has authored over 100 peer-reviewed publications, is a popular speaker on the international scientific meeting circuit, and serves on the editorial board for several scientific journals. He has been successful in obtaining over £4 million in competitive research grants, both from public grant bodies such as NIHR, BHF, as well as from industry, and he has served as a chief investigator for several multi-centre ablation clinical trials. Professor Gupta has supervised and examined PhD candidates for Imperial College London, University of Liverpool, Queen Mary University London, City University London, and University of Birmingham. Thank you for joining us. Our second panellist is Dr. Soroush Kiani, a cardiologist and cardiac electrophysiologist in Worcester, Massachusetts. His top areas of expertise are electrophysiology, cardiology, and internal medicine. He is actively engaged in clinical research in the area of EP, including as a principal investigator in a clinical trial for vascular closure for atrial fibrillation procedure. Thank you for joining us. We're looking forward to hearing from you both. So, thank you very much for that kind introduction. I'd like to, Lauren Rousseau and I would like to thank the Heart Rhythm Society and our esteemed colleagues for giving us the opportunity to present to you today. So, the title of our talk is going to be same-day discharge and EP procedures, protocols, and next-day follow-up, and this talk is going to be a tag-team presentation between myself and Lauren Rousseau, and this is in keeping with the idea, the concept that this is a team approach, same-day discharges, and it's a team approach that involves the physicians, the allied health professionals, who are absolutely essential in the success of such a strategy. Next. So, the objectives of our presentation are shown here. We plan to discuss the evolution and post-procedure disposition and same-day discharge strategy. We will review the implications and benefits of same-day discharge and discuss issues related to safety and efficacy, hospital resource utilization, and cost issues. We also plan to review protocols to standardize post-procedure discharge, and in particular, we want to share the protocol that we've used at our institution as an example, and also, in keeping with that, we want to review the same-day discharge experience at our institution as an example. Next. So, there are a number of items to consider when a same-day discharge strategy is to be employed, and a number of these considerations are shown on this slide. First of all, patient selection and how you go about patient selection. So, before engaging in a strategy, it's good to think about what the rules are going to be, what type of protocol, what is the eligibility for patient selection, but also to have a component of operator discretion. So, when we started with a same-day discharge protocol for some of our more complex ablation procedures, we did, as you'll see later in Lauren's part of the presentation, we did establish some, we established protocols, but we did have a caveat where the operator had discretion in terms of which patients were deemed eligible, and before each procedure, we would say ahead of time, this patient is eligible for same-day discharge, and what we observed, and you'll see this as a theme today as well, is that initially, there's a bias towards younger patients, patients with less comorbidities, but as time moved forward, that difference in patients that were undergoing same-day discharge compared to those that were staying overnight became less, and that we became more comfortable with older and maybe less healthy patients. Secondly, the role of allied professionals in the process, this is absolutely essential, as you'll see at our institution, the allied professionals played an essential role in the development of the protocols, and also they play an essential role and the main role in the oversight of the disposition and discharge process. We couldn't do it without them, definitely. Also, issues related to observation time, bed rest time, we had to think about how long do we want to watch patients initially after the procedure, and we set some pretty strong rules. We were conservative at first, and you'll see with Lauren's presentation, but as time moved forward, that observation time, we began feeling more comfortable making that shorter. Issues related to vascular access management, how long patients lie flat, and potentially issues related to possibly vascular access closure devices. One also has to think of standardizing protocols in general, and this type of strategy really needs standardized protocols to be successful. Then another general consideration has to do with timing of discharge. We talked about same-day discharge, but we've taken a broader sort of view, a broader approach, not just in terms of same-day discharge, but disposition in general. So, issues related to overnight observation, extension of our recovery unit times to accommodate for longer observation times, and potentially overnight in the recovery unit so that in-hospital beds utilization can be avoided. So, all of these are considerations in same-day discharge procedures, and finally, telehealth utilization strategies are important to be employed as part of the same-day discharge and disposition pathways approach, and this includes virtual visits as well as remote monitoring technology, and we've employed both aspects of telehealth in our protocols in same-day discharge. Next. And another way of thinking about things is thinking about sort of the pros and cons of the same-day discharge process, and this slide kind of elucidates some of the issues that we weighed on the pro and con side. So, first of all, at the upper left-hand corner, you know, there's definitely the potential for patient convenience, increased patient satisfaction with the thought of being able to go home the same day after a procedure, but on the con side, there are some patients who feel a sense of unease if you're told that you're going to send them home after maybe a more complex ablation that involves general anesthesia, transeptal access, and multiple catheters in the veins, et cetera, and so that has to be weighed, and we weren't sure how patients initially would respond, but what we found was that it weighs very heavily on the pro side and that the vast majority of the patients view the opportunity to be discharged on the same day as a huge plus, and actually, there are some patients in whom the thought of being able to be discharged on the same day actually affects their decision to have the procedure done. Knowing they can be discharged the same day with some patients is the deciding factor in undergoing the procedure in the first place. Secondly, reduced hospital resource utilization and cost savings is an important consideration on the pro side, but on the con side, just because we reduce hospital beds and inpatient resources, there's a shift in resource utilization in other areas, so having patients stay longer in the recovery area requires more resources in that regard, so it's a trade-off, and once again, through a preliminary analysis at our institution, we found that the costs benefit weighs in favor on the pro side of this issue as well. We talked about, I spoke about the potential for utilization of telehealth technology as a huge plus for managing these patients, but on the con side, having patients at home, there's the potential for a greater impact of a complication if it occurs at home versus in the hospital, so this is where patient selection is very important, and we've been successful at, in this regard, at reducing the incidence of, or of minimizing and avoiding the incidence of severe complications at home, and as you'll see with some of the literature that I review in the coming slides, this has been true in publications as well, and we talked about the opportunity for an expanded role for allied health professionals, but on the con side, there's, there's less time for post-procedure planning and in-person patient education, and this is where, you know, efficiency really needs to come into play, and it forces us to be more efficient in delivering this information. Next. Next. So, this slide just shows a visual sort of story, a representation of what, what I would expect a lot of centers have evolved through in terms of the evolution of same-day discharge in EP labs over time, and, you know, initially, this type of strategy was limited mostly to general EP studies and simple ablations, like typically right-sided flutters or SVTs, simple SVTs, and over time, a lot of centers such as, such as ours evolved to have a strategy of same-day discharge with device implants, so first pacemakers and ICDs, and then extending into all forms of device implants, CRT, leadless pacemakers, left atrial appendage occlusion, and subcutaneous ICD, and then, and then a further evolution into more involved, complex procedures that might involve general anesthesia, transeptal access, such as AFib ablation, and, and basically everything else, and at our institution, pretty much any procedure can be considered for same-day discharge now in, in our, from our EP lab, and it's really, you know, still a little bit about patient selection, but, but we've, we've done same-day discharges in pretty much every procedure we offer, every type of procedure we offer now. Next slide. So, as I mentioned, early on, the, the, before there was a lot of same-day discharge going on in, in complex ablations, AFib ablations, and even more complex ablations, the, there was a, a push for same-day discharges in, in devices. This slide is a, is a grid that just shows a summary of a number of different studies that have been published on the topic of same-day discharge after device implant procedures, and at the top, the, some of the earlier studies in the early 2000s are shown, and a few things I'll point out. First of all, nearly all of these studies are cohort. Most of them are retrospective. Some use registries. There's one randomized controlled trial shown on the second line on this grid, but for the most part, it's, it's cohort studies. I'll also point out on the, on the right side of the grid that these studies, these publications come from a number of different countries, and we look, we have a, a, a steamed panel today of people from a number of different parts of the world, and we look forward to our discussion afterwards about where some of the challenges lie or what some of the issues are that may relate to same-day discharge in one region of the world versus others. Next slide. Oh, and actually, one last thing I'll mention about the previous slide is, it's not just pacemakers and defibrillators. There have been same-day discharge publications that relate to leadless pacemakers, subcutaneous ICDs, left atrial appendage occlusion devices, and all of these studies on this slide demonstrated good safety and outcomes in same-day discharge. Next slide. So, there's been a progression to employing same-day discharge strategies with complex ablation procedures, and because atrial fibrillation has increasingly occupied a greater and greater percentage of ablation procedures, we'd like to spend a little bit of time discussing this as well. Now, some of you, the way afib ablation has evolved, whether we consider it a complex ablation procedure, there, you know, some people may describe it one way or the other, but nonetheless, it involves general anesthesia, transeptal access, spending a fair amount of time in the left atrium, high levels of anticoagulation. So, there's a lot of complexity and potential for complications with this type of procedure, nonetheless. So, what are some of the motivators? Why have people evolved to do same-day discharge, or what are some of the justifications for same-day discharge with a procedure like afib ablation? Well, first of all, the complication rate has gone down over time. This slide shows some data from our institution that was published in 2017 at HRS, and we looked at two different groups of patients, one group of our afib ablation patients from 2009 to 2011, and compared the complication rate in that group to a group from 2014 and 2015, and as you can see, complications, every type of complication has decreased dramatically over time, and we have data more recently where, you know, demonstrating the complication rates have gone down even further, and this has been borne out in the literature and other areas as well. So, a lower complication rate makes people feel more comfortable about sending patients home. Next slide. Secondly, not only is the complication rate gone down, but when serious complications do occur, they tend to occur very, either during or very early on after the afib ablation. This slide shows some data from Sweden, from a publication from Sweden, where the investigators looked at over 5,000 afib ablations and looked at the issue of complication rates after afib ablation, and first of all, they found that the overall complication rate was very low, and secondly, and importantly in regards to, in the context of what we're discussing today, the vast majority of major complications occur either during or within the first six hours after the ablation procedure, so this also helps to justify sending patients home the same day. Next slide. And finally, what is another motivator for same-day discharge after afib ablation? Well, volume. So, the volume of ablations has increased exponentially over time, and in nearly all parts of the world. This slide shows some data that was published from Sweden, on the left, and from South Korea, on the right showing the number of AFib ablations, I'm sorry, the number of overall ablations increasing over time. And the biggest component of ablation volume increases is atrial fibrillation. And then in our institution and in the United States, the percentage of ablation or atrial fibrillation occupies an increasing percentage of ablations. And now in the U.S. over half of all ablations are AFib ablations. And at our institution, it's well over half in the 60% range as well. So with increasing volume, we have to be able to accommodate these patients. And so many hospitals now, including ours have bed capacity limitations and being able to send people home the same day or overnight in a recovery area without having to go up to the floor and occupy a bed. Well, that helps to lessen the burden that these increasing numbers of AFib ablations would occupy. Next slide. So as I showed the earlier slide with a list or a chart of publications from device same day discharge, this slide shows a chart of quite a few publications in the literature on the topic of same day discharge after AFib ablation. And this is just to show that this is not an entirely new endeavor. And there's a lot of literature to support same day discharge for AFib ablation. So if you're a center that's thinking about engaging in this type of strategy or increasing the volume of patients that you send home the same day after AFib ablations or complex ablations, you can rest assured that there's a lot of data, literature to support your efforts or what you're doing or justify what you're doing. The first study shown at the top of this chart is related to SBT ablation. I just included this to show that this concept goes back quite a ways in time. This was from 1993, but all of the rest of the studies shown here are from studies looking at AFib ablation. A few things I'll point out once again, these are all prospective or I'm sorry, these are all cohorts, the majority of which are retrospective cohorts. There are some claims databases and things, but there are no randomized controlled trials on the topic. But frankly, this is something that would be hard to do. We could sit and argue about whether it's necessary. Personally, I think it's probably not something that's needed because there's a lot of good data from studies like this, matched studies and things like that. The other thing I'll point out once again, if you look at the column on the right is that these studies come from various countries, all parts of the world. This is an important topic in many places. And like I said, we look forward to hearing the perspectives of our international panel on same-day discharge and post-procedure management and how there may be some unique issues in different parts of the world. Next slide. From the last study that was shown on that slide, this is a study that was published by Dr. Field in 2021. And this is from a claims registry database and a propensity analysis comparison group. And what the investigators kind of showed in this study was that there were no difference in complications between same-day discharge and overnight stay patients in their analysis. So on the left, the overall composite complication rate was not statistically different between same-day discharge and overnight stay. And looking at some of the more common types of complications, cerebrovascular events, vascular access events, pericardial effusion or pericardial complications, there were no significant differences between the two groups. And these were matched controls to the same-day discharge group. And the one-year AFib readmission rate was not statistically different either. So it's felt to be safe and similarly effective. Next slide. And with all of these studies that have been published, there have also been meta-analyses performed. And this slide shows data from two of these meta-analyses. And once again, there is a strong signal towards safety and similar readmission rates between same-day discharge and overnight stay patients. Next slide. So what are some of the common themes of these publications and studies? Well, the publications are predominantly retrospective cohorts, like I mentioned. A defined protocol is often described in these studies and we'll share our local institution protocol in the next part of our presentation. Initially, selected same-day discharge patients tend to be younger with less comorbidities but these differences become less over time. The percentage of same-day discharge overall increases over time. And there does not appear to be observed differences in adverse events or readmission in same-day discharge. Next slide. This slide just shows some temporal and trends and some regional trends in two types of procedures with regard to same-day discharge. On the left, there's a graph showing temporal and regional trends in same-day discharge after AFib ablation. And you can see that the percentage of patients that have undergone same-day discharge has increased dramatically over time. And that at least this is from the United States that the West Coast, this is from a cryoablation study but at least in this study, there seemed to be a greater adoption on the West Coast and the East Coast tends to lag and be a little later adopters, but we're catching up. And this seems to happen a lot. We on the East Coast seem to adopt things a little later than our West Coast colleagues. And on the right, there's a temporal trend graph with regard to left atrial appendage occlusion. And this is from a publication from AGC in 2022. And the percentage of patients after left atrial appendage occlusion being discharged same day is much lower than AFib ablation but it's increasing significantly over time. And these numbers are the rate for 1000 left atrial appendage occlusion admissions. Next slide. What about costs and savings? This slide shows a summary of a number of different studies that have looked at the issue of cost savings from same-day discharge. At the top, the first line for historical reference is a study from over 30 years ago, looking at savings from sending people home after diagnostic EP testing. The next two rows are from studies looking at the issue of device implants and cost savings. These are from the UK. And then the remainder of the rows are from publications that looked at cost savings from AFib ablations from a number of different countries. And Lauren and I tried to take these studies when and when not it wasn't presented in the study, we tried to estimate the savings per patient and that's shown on the column all the way to the right. And you can see that the savings are in the two to $1,600 range per patient. But with the volume of something like AFib ablation or device implants, this equates to a significant overall cost savings per year. Next slide. So to summarize my first part of the presentation, the same-day discharge is justified, it's safe, it saves costs, and there are lots of other potential benefits, including patient satisfaction. What are some of the future directions of same-day discharge? Well, I put the first line up above, same-day discharge, I wouldn't say it's the future, it's the present. There's many institutions that have adopted this, there's a lot of literature. So I would say it's the present and the future. And it's here to stay. There's so many more reasons to engage in this strategy than not to engage in this strategy. But what's needed? Well, a more comprehensive approach to patient disposition is needed. Not just to think in terms, not just of same-day discharge, but overall disposition of the patients, ways that we can avoid the utilization of inpatient beds, defining the roles of the team and how physicians and allied professionals will work together, and clarification of needed resources. When we engaged in our same-day discharge program, we worked closely with the hospital administration at our institution to identify what resources were needed, what types of personnel, how we need to shift certain types of resources to accommodate same-day discharge. And finally, it has to be patient-centric. And so as time goes forward, we really need to approach this in a patient-centric manner, because it really has to start with the patients and how this benefits them. Next slide. And now I'll turn over to the second part of our presentation. And Lauren Rousseau, one of our PAs who works with us, our allied health professionals, will present the remaining part of the talk. Thank you, Dr. Copeland, for that great overview of the publications that we have on same-day discharge. And thank you, Heart Rhythm, for asking me to be here tonight. It's a true honor. So we're now gonna transition to talk about our experience at Brigham and Women's Hospital. So Brigham and Women's Hospital is an 812-bed tertiary center where we perform about 1,200 ablations a year. And I wanted to show this slide just to acknowledge our care team involved in our program. So as you can see here, we have a great group of physicians, allied professionals, laboratory cardiovascular techs, and nurses staff that really helps make our program successful. So we're gonna talk about the evolution of EP procedure dispositions at Brigham and Women's Hospital. So we first started sending our cardiac device implant patients home the same day back in 2015. And as all of you know, in March of 2020, the COVID-19 pandemic hit the United States, and it really forced institutions worldwide to reassess how we can manage elective procedures and try to avoid overnight hospitalizations. All while keeping in mind, trying to avoid exposures to patients and providers. So in December, 2020, we decided to create an AFib same-day discharge program. We kept track of our success rate and noted that we had a success in sending our patients home just under 65% of the time. In December, 2021, we decreased our bed rest time from four hours to three hours to reducing our observation time and hoping to get our patients home sooner. In January, 2022, we reassessed our AFib same-day discharge program and the success rate and was noted that it had improved from about 65% to now close to 85%. In February, 2022, some of our proceduralists started using vascular closure devices. Again, with the hope to shorten the patient's bed rest period, shorten their observation time and get them home sooner. And then in August, 2022, we took a broader approach at assessing EP disposition pathways. And the hope was to help manage ongoing bed capacity challenges and reassess our post-procedural management in these patients. So we're gonna first start with reviewing our AFib same-day discharge program that we first established in December, 2020. So this was our initial protocol that we created in December, 2020. And we noted that it was essential to have this protocol to ensure patient safety and efficiency. And this was something that we started prior to the patient's arrival to the hospital. So we told patients that it was possible that they would be going home the same day following their AFib ablation. So in that case, that would mean that the patient would require a ride to and from the hospital and they would need someone to spend 24 hours with them post-procedurally. In addition, the attending must have felt that the patient was appropriate for same-day discharge with no concerning features during the case. And the case had to be completed prior to 3 p.m. So this would allow for adequate observation time in the recovery area and would also allow for the allied professional to then assess the patient over education and then send them home all while maintaining the allied professional's shift end. In the post-procedural phase, the patient's vital signs must have remained stable without any recurrence of arrhythmia. Their bed rest must be complete without any vascular concerns. The patient must be ambulating and voiding without difficulty. They should be tolerating PO intake and then able to comply with a virtual visit the next day with one of our allied professionals. So the telehealth visit was really essential in the periprocedural management of these patients. So our allied professional would send a message to the patient the following day asking them to send us their weight, their blood pressure and their oxygenation status and then send them their rhythm strip. Now they could send us their rhythm strip by one of three ways. If the patient had an implantable cardiac device, they can simply send it a transmission. If not, patients could also send us a heart rhythm strip by their Apple Watch or a CardioMobile device. And we found that most of our patients had one of these three modalities. However, if not, we sent them home with a cardio device where the patient then could check their heart rhythm the next day and then we had asked that they send us the CardioMobile back within a week of the procedure. This was really a great way to reassess the patient post-procedurally to address any unanswered questions or concerns that the patient may have and then to reinforce the post-operative education. So this data was presented last year at Heart Rhythm. And in our initial experience with our AFib same day discharge program, we wanted to keep close track on the reasons why patients who had been intended to go home the same day were unable to do so. So we had hoped that if we kept track of this, that we can then improve our success rate over time. So we found that the most common reason why patients were unable to go home were due to vascular access issues. So patients developing hematomas or bleeding. Other less common reasons were patients feeling unwell or having vasovagal episodes, neurologic issues or inability to avoid, arrhythmia, recurrence, and then less commonly pericardial effusion, medication reaction and heart failure. So again, this data was also presented last year at Heart Rhythm. And so we wanted to assess our initial third of patients, our middle third and our most recent third of patients and our success rate over time. So we looked at our intended patient population and our intended same day discharge and noted that those patients over time increased in age and with comorbidities. And then we also noted that the success rate of our same day discharge was improving over time as well. And we think that this was due to the comfort level of our nursing staff, our provider team, and then also having that telehealth visit where it would provide reassurance for the patient and the provider given the close follow-up. So again, I would like to just stress our initial same day discharge program, which was limited by a 3 p.m. time stop. So patient's ablation had to be completed by 3 p.m., which then would allow for adequate bed rest time and appropriate observation. So we're now going to shift gears and talk not only about same day discharge, but overnight observation and the location of observation. So we'll jump ahead to August, 2022, where again, our institution was trying to combat ongoing bed capacity challenges. And we were trying to come up with a creative way where we can optimize patient's observation time and improve discharge efficiency. So the first thing that we recognized was that we needed to increase the time in which our recovery room was open and available. And so we then went even further and considered having patients spend the night in our extended recovery unit. And the purpose of this was to reduce inpatient hospital bed utilization and optimize patient disposition pathways for all patients who are presenting for EP procedures. And we hoped that this would improve discharge efficiency all while maintaining patient safety and satisfaction. And so we recognize that an extended recovery unit may be reducing resources on the inpatient level of care. However, it still requires additional resources, including space and a care team. So our extended recovery unit included six patient beds with two registered nurses and provider coverage. So again, a team approach making sure that we can provide the utmost care in the post-procedural management of our EP patients. So in the setting of extended, our extending recovery unit, we wanted to optimize a disposition pathway protocol. And so patients could fall under one of these three pathways. Any patients presenting for an EP procedure could be either sent home by same day, by conditional discharge or an admission to the EP allied professional service. Those patients going home the same day would be sent home the same calendar day as their EP procedure. They would be evaluated by the allied professional prior to discharge. And then they would be seen the next day by a telehealth visit. Patients undergoing the conditional discharge protocol would be discharged by a nurse-driven protocol and would be sent home without an evaluation by the allied professional. So this generally would be after 7 p.m. when the allied professional shift ends or prior or around 7 a.m. when the allied professional starts their shift. And then the last pathway is patients admitted to the EP allied professional service, at which time the patient would be assessed by the allied professional in the morning and then most of them sent home that next day. So patients in the conditional discharge pathway had to meet specific criteria to be discharged home by the nurse. And we felt that it was essential to have specific criteria in order to avoid hospital bounce back and post-procedural complications. And so patients meeting these specific criteria could then be sent home safely. The criteria included vital signs that were stable during recovery. They must have no recurrence of arrhythmia. They must have completed bed rest without any evidence of hematoma or bleeding. They must be ambulating and voiding without difficulty and tolerating PO intake. So we assessed all patients presenting for EP procedures. Those patients who are inpatients remained admitted while the other patients were considered eligible for the disposition pathways. We assessed those patients who were admitted to the EP AP service. And then those patients again, who could be eligible for the other pathways, including same day discharge and conditional discharge. Any patients who didn't meet criteria for conditional discharge by the nurse-driven protocol would then cross over to the failed conditional discharge and then would be evaluated by an allied professional the next day. So we would love to share these results with you. However, we have an abstract that is currently submitted. And so we hope to share the results with you in May of this year. So we have theorized that creating an extended recovery unit would reduce the total time spent in the hospital by patients. And that earlier discharge would represent opportunity costs to make room for subsequent patients requiring care. Those patients discharged either same day or conditional discharge by the extended recovery unit would then represent hospital beds saved. And so again, we would like to acknowledge that although we may be reducing inpatient resources, we are shifting resources into a different area in our extended recovery unit. And it does require additional space and care team members. In addition, because our extended recovery unit not only cares for patients post-procedurally, but also pre-procedurally, it's important to keep in mind that you want to avoid inhibition of throughput and making sure that we have room for our pre-procedure patients while our post-procedure patients are still recovering. So with that, I'd like to hand it back to Dr. Copeland to discuss our conclusions. You're muted, Bruce. Thank you. Thanks, Lauren. So in conclusion, the management and disposition of patients after EP procedures has numerous considerations that encompass continually evolving strategies. The keys to the success of a same day discharge program are to recognize that a comprehensive approach is required. There's a central role for allied health professionals in that comprehensive approach. It's important to set up protocols that can be followed by such a large team. And obviously, safety has to come first. And it's also important to track what you've done to show the benefit. And finally, we like to think of this as a triple win. First and foremost, it has to benefit the patients, but also it has to help the hospital to be able to provide care in a tightening bed control environment and cost savings environment. And finally, it has to help the providers to be able to provide the care they need to provide to the patients in an efficient manner in order to be able to fit in all of the care that needs to be given. Our references are shown here. Next slide. And finally, we'd like to thank the Heart Rhythm Society and our esteemed colleagues for giving us the opportunity to present today. Thank you, Dr. Copeland and Lauren for the informative presentation. I would like to remind the audience to post their questions in the Q&A section so that we can relate esteemed panelists to get their views on the presentations and to share their experience. Welcome, Dr. Gupta and Dr. Dhani. Hi. Hi, thank you very much. Dr. Gupta, we can start with you. Can you provide your perspective on the practice of same day discharge throughout Europe? What are the unique challenges and what are some of the ways that these challenges are being addressed? Thank you, Dee, and thank you to the Heart Rhythm Society for the very kind invitation to me to provide a sort of perhaps an international flavor on this very important subject. So I'm based in Liverpool and we started doing same day discharges following AF ablation quite a long time ago, actually, back in 2014. And then we published our first five year experience in 2020. Now, we started slowly, a bit very, very similar to what Bruce and Lauren have described their experience. We were very careful initially. And the default strategy used to be that patients had to be staying overnight and we had to find reasons to be able to let them go home. Obviously, over time, the strategy has evolved so that now the default approach is for everybody to go home and there have to be specific reasons why patients need to stay in overnight. A lot of things have helped in the same day discharge process. AF ablation has become increasingly a non-complex procedure. In Europe, we tend to use general anesthesia less often than in the US. That helps. We don't tend to use Foley catheter quite so much. Again, that helps as well. But what I think has made a huge difference is the better groin management, which helps in early mobilisation and same day discharge. So, for example, the use of uninterrupted oral anticoagulation, that's really helped. Some of us will remember the time when we used to give Clexane to all of these patients, but obviously we don't do any of that. The use of ultrasound to guide vascular access has made it much easier and the groin complications has reduced as well. And also now use of vascular closure devices. So, for instance, now a default strategy is to mobilise patients after three hours and send them home after four, which means that we can even start discharging patients whose procedure is finished after the three o'clock cutoff, which used to be the case in Europe or certainly in Liverpool, as is the case in Brigham and Women's as well. Now, the European Heart Association performed a survey of physicians in Europe looking at the practices for air fibrillation and same day discharge, and we were struck by the wide variation in different health systems. We saw that the success or otherwise of same day discharge depended upon a number of factors. The most important being the volumes of air fibrillation being performed at the individual centre, because that then related to the perceived complexity of the procedure. The more the number of air fibrillation being performed in a centre, the less complex the procedure was perceived to be, the shorter the duration of the procedure itself, which made it more comfortable for the whole team to view this as a straightforward procedure in which patients can go home. But another thing that struck us was that the reimbursement systems are very different in various countries. In some countries, in fact, there was almost a perverse financial incentive for hospitals to keep patients because they won't get fully reimbursed for the ablation until this patient stayed one night, or in some countries, two nights. That's being addressed, I understand, in those countries, but certainly in the UK, where we are always fighting, you know, with a diminishing bed base, there has been a strong reason for us to really help patients go home the same day. And that process was really accelerated during the COVID pandemic, as beautifully put by Bruce and Lauren. You know, we had to send patients home the same day. And so we put into place processes very similar to those described, you know, just now. As of now, the approach is very much everybody goes home until there's a very good reason to keep them in hospital. Thank you. Thanks, Dr. Gupta. Bruce and Lauren, great job with your presentation. Thank you so much for that. Praj, I just wanted to throw this over to you real quick. Can you give us a quick overview of the Australian experience with same day discharges? Yeah, I mean, I think it's very similar, although we are a stage back from where Duraj has kind of mentioned here. So with devices, with SVTs, I think that's now standard practice. So I think we've moved to that pretty well. We've only got some early adapters in terms of AF ablations going home at this stage. We do have a health system that prefers to keep people in, but we are under the COVID pressures of not having enough beds. And so we are now accelerating, they're looking at protocols of how we're going to send people home and make the whole team, including the patient, feel comfortable about it. So this experience has been huge in terms of providing reassurance of being able to send people home. So congratulations on the work that you guys are doing, because I think it's going to be informative for us to move forward in terms of same day discharge. Thank you, Praj, for the Australian experience. Do either of the panelists currently do AF ablations at a center without cardiothoracic surgery on-premises? If so, does that influence your decision on same day discharge? We have on-site cardiac surgery where I practice. I'm not sure that that's what influences my decision on same day discharge, but I guess that's easy for me to say because I have access to the surgery. Ditto for us in Liverpool as well. We're very lucky, we've got a very large surgical support backup, but I am aware of other centers in the UK which have published their same day discharge data from centers which do not have on-site surgery. For instance, there was a paper published by Richard Schilling's group in which they performed cryo-balloon PVIs in a small district general hospital which didn't have on-site cardiac surgery and patients were discharged on the same day. I think what has really made the procedure, what's made same day discharge possible is the reduced risk of tamponade during the procedure and afterwards. And I think I wanted to ask, perhaps I'll ask Bruce and Lauren as well, something that used to be done in England, which is now less often done, is routine echoes a few hours after the procedure prior to discharge just to make sure that there isn't anything brewing? Is that something which you guys consider doing at all? Yeah, when we started with our same day discharge strategy, we did a quick look bedside echo. So we did that initially because as you allude to, that's the one of the main types of complications that you would not want to accidentally send somebody home with. And over time we stopped doing it as a matter of routine. We look at the vital signs, how the patient feels, we feel like we've watched them long enough that if they were going to have something evident that we would have known by the time they're discharged. And then along the same lines of the earlier question about cardiac surgery, regardless of whether you have cardiac surgery or not at your institution, there's no cardiac surgery at home. So that does not influence our, that I don't feel that that influences our decision about whether or not we do same day discharges. So Roosh, we're getting a lot of questions about groin access and closure devices. Yeah. You've done, you've done some work on that. Can you tell us what you found and how that impacts this whole same day strategy? Yeah. I mean, I think two, sort of the two big arenas in vascular access issues have been the access itself and then getting out. And as Dheeraj pointed out in the era of ultrasound guided access, micropuncture, I think getting in has gotten a lot safer and a lot less complicated. And then on the tail end of the procedure is getting out, what our group in our trial, as well as Andrea Natalia's group in the AMBULATE trial found is that in AFib procedures, vascular closure does seem to reduce the time to hemostasis and facilitates earlier ambulation for most patients. At least if the closure is successful, which most devices have a very high success rate once operators have sort of traversed the learning curve. So, you know, we found that with suture mediated closure, we had success at one hour ambulation in a subgroup. We sort of did a secondary randomization and mobilized people at one hour. And that was no different than two hours, which is sort of institutional practice for successful vascular closure. And those patients who were planned for same day discharge got out commensurately earlier on the same day with no difference in complication rates. Although I'll say because the rates are so low, it's really hard to detect some of these differences sometimes, but at least it seemed to be a safe and effective way of doing things. Thank you, Lauren. I wanted to address this next question to you because some other questions came in on the chat about the extended recovery unit. So some of the specifics that people were inquiring about, how long do you keep patients in the ERU after a vascular closure device? And have you ever had any difficulties when patients were later in the extended recovery with families not wanting to take the patients home with them, or do they all just stay overnight? So if you could address those, that'd be great. Yes, of course. Thank you. Yeah. So we, as I noted earlier, we just started using some vascular closure devices. And so generally it's two hours after a vascular closure device. However, we have sort of set like a three hour observation time. So they're able to get up and mobilize after two hours and then that allows them to hopefully void sooner and then start our education process and then hopefully get them out the door around three to four-ish hours. In terms of sending patients home later, that was one of our concerns when we started this program, you know, like who's going to want to drive home at 10 p.m. or who's going to want to pick up their patient, their family member at 10 or 11 p.m. And so we've given them that option to do so. Again, if they're meeting the conditional discharge criteria and that they and their family feels comfortable in picking them up and bringing them home, or they can spend the night. And so we say, that's fine, you can spend the night and then we hope to, you know, get you home by 7 or 8 a.m. the next day. Again, as long as they continue to meet that criteria. Thank you, Lauren. Back to post-procedure complications, have either our panelists or presenters seen any delayed complications? So seven days following a procedure, either afib ablation or left atrial appendage closure device. Okay, if I can go on. Yeah, sure. Sorry. So the incidence of that is definitely not zero. As you presented as well in your presentation, Bruce, there was a paper which very nicely looked at the chronicle, you know, in time to see this complication. And there were a few complications that occurred beyond six hours as well. So usually these tend to be either growing complications, you know, which happen delayed, or there will be pericarditis or arrhythmia recurrence. So one of the important things which I think is well worth addressing is education and having a support network for patients. So if patients go home the same day, they have to know who to contact, if they get any red flag symptoms, what are the red flag symptoms that they should be worried about. And I think having that kind of having perhaps telephone helpline helps a lot. And also giving them a leaflet with symptoms, you know, which ones are to be expected, for example, a bit of pericardic pain will be expected. You know, your heart being a bit jumpy or irritable, that's again to be expected, perhaps a bit of upper GI discomfort, again, you know, it's not unexpected. But if the pain becomes really severe, or if there are problems in breathing, for example, heart failure, that can be an issue in patients, especially if they've got a left radial dysfunction, then they need to contact us. A lot of patients feel confident with the symptoms. Initially, when we started a similar discharge program, we had a spate of phone calls in the days after discharge with patients who were just concerned. And even if there was a small bleeding from the groin, they would call back because they didn't know that was expected, or they were getting, you know, a bit of chest discomfort, they would be worried. And I think over time, you realize that if you prepare patients for this beforehand, then they are much more likely to take it, you know, take these symptoms in this fight. Dr. Raj, if I could add, I mean, I think that's true, same day or next day discharge. I mean, as you point out, these complications that are more delayed, aren't going to get caught in 24 hours anyway. And so I think what you said is very poignant, and I think it's true regardless of when the person is leaving the hospital. Yeah, and I would add also, you're not missing the entire time that complications can occur, it's a, you're missing a window, a small window. So some of these, when we see complications after discharge, we think to ourselves, we like to, we review all of our complications at our institution, I'm sure you guys do this too. But, you know, would this have made a difference if the patient stayed overnight or not? Because some, a lot of these complications that are delayed would have happened after an overnight stay and a discharge anyways. Great, Lauren, I just wanted to address another question to you. You talked a little bit about same day discharges requiring a shift in resource utilization, particularly in terms of staffing. What additional training requirements for Allied Professionals are extended care staffing requirements? Obviously, this needs, you know, hospital buy-in to provide the space and the extra staff to make this happen. Yeah, no, absolutely. And I would say for Allied Professionals, it's not a ton of additional training because our Allies now are caring for patients virtually, and we know how to manage our post-procedural eighth of ablation patients now, both, you know, in the hospital and outside. I would say that the biggest learning curve or education occurred for our nursing staff, because especially if patients were being discharged by the nurse in the extended recovery unit, a lot of those nurses had never discharged patients before because they would spend the night and they would go to an inpatient unit. So that was a big learning curve. And so we had to review with them the potential complications, things to educate the patient on, things to look for, et cetera. And then in terms of the resources, our Allied Professionals, because we used to see these patients in the hospital on, you know, the following day, post-op day one, we're now seeing them virtually. And so we didn't necessarily need additional resources. It was just seeing our patients in a different way. So again, not in the hospital, but virtually. We have had another question in the chat that I'd address to Bruce and Lauren. Are there patients that you just would not consider for this? You know, is there anyone up front that you would say, we're not going to do a same day discharge and you are going to be an inpatient? Lauren, do you want to go first? Yes. So we don't have like a, you know, a definite protocol and like this type of patient definitely needs to stay, but there are higher risk patients that, you know, they have a low EF, they got over two liters of fluid. We cardioverted them four times. And so generally we would admit them to the Allied Professional Service. So those patients generally, you know, they're on tele overnight, they get labs in the morning, they have strict eyes and nose, the Allied will see them in the morning and then decide, can they go home? Do they need to stay for further diuresis, et cetera. So yeah, it's a bit more on a case by case basis. We don't have a set protocol on specific patients. And I would, I would add, yes, there are patients in whom we would consider, or we would want to keep over, but there's not a procedure that we wouldn't consider for same day discharge. And that's how we've evolved into. Right. Dheeraj, you had a comment? Yeah. Just to build on what, you know, what we just said, that there are some procedural reasons, and then there are some patient specific reasons why you wouldn't want to let them go home. For example, from the procedure point of view, exactly as Lauren said, anybody with a significant left frontal dysfunction, heart failure, we will tend to keep overnight because these are the patients who can deteriorate after six hours. And you don't want that to happen once they're home. When it comes to patient specific reasons, they're more social. For example, elderly patients who perhaps stay all by themselves, who perhaps live a long distance away. You know, there can be a two or three hour drive away from Liverpool, for instance. So those are the patients we would ask them at the outset when we are listing them. You know, what kind of a network do you have at home support network? And if you think that there is any risk that they may be left unprotected, and they don't have anybody to look after them, then we have a low threshold for keeping them overnight. If I could also add, I mean, I think, as Bruce pointed out earlier, there's a higher, patients prefer, generally speaking, in my experience, to not want to stay in the hospital. So my 100% criteria is if a patient asks if they can stay, the answer is yes, that patient's not going home. And my reason is there's a, I mean, that patient will often have a very good reason, either some of the ones that were already pointed out by Lauren, by Duraj, or, you know, something subconscious or sort of gestalt that maybe I or someone else hasn't picked up on. So my other absolute criteria for someone I won't consider for same day discharge is someone who doesn't want to be discharged, because it's not clear yet that that's always the right answer. Yeah, I would agree. We take a similar approach that we don't force anybody to leave. Look, everyone, thank you very much for this very detailed and I think informative session, which is going to change practice. I think a lot of people around the world be looking at how to do this, and you guys are leading the way there. So thank you very much. And I want to thank all the people online who've been participating and sending in questions. And just a reminder to everyone that this is something that you can claim CME on and the details of this how to do this is just now being put up online. And this recording is obviously available on HRS 365 if people want to look at it afterwards. So thank you very much to all the speakers and our panelists for joining us today to take part. Thank you. Thank you.
Video Summary
In this webinar, the speakers discussed the practice of same-day discharge after electrophysiology (EP) procedures. They emphasized the importance of a comprehensive approach, involving both physicians and allied health professionals, in order to ensure patient safety and efficiency. Several factors were highlighted as important considerations for same-day discharge, including patient selection, protocols for post-procedure discharge, and the use of telehealth technology for follow-up visits. The speakers also discussed the evolution of EP procedure dispositions at Brigham and Women's Hospital, including the establishment of an AFib same-day discharge program and the implementation of an extended recovery unit. They shared data on the success rates of same-day discharge and the factors influencing these rates over time. The speakers acknowledged that the practice of same-day discharge can vary across different regions and health systems, and highlighted the importance of a multidisciplinary approach and standardized protocols in ensuring the success of same-day discharge programs. The panelists also discussed the challenges and benefits of same-day discharge and the use of vascular closure devices in the EP setting. Overall, the speakers concluded that same-day discharge after EP procedures is safe, can lead to cost savings and improved patient satisfaction, and is a practice that is here to stay.
Keywords
webinar
same-day discharge
electrophysiology procedures
comprehensive approach
patient safety
efficiency
patient selection
follow-up visits
success rates
multidisciplinary approach
cost savings
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