Hello. Welcome to our talk. I'm Dr. Raymond Miller, cardiac electrophysiologist at Bay Health Medical Center in Dover, Delaware. Hi, and I'm Ben Collins, senior director of operations at the cardiovascular service line here at Bay Health. We're here to talk about the navigating same-day discharge, decreasing readmissions, and improving patient satisfaction. So our problem statement here is, can established same-day discharge criteria for PCI be expanded for the use of EP procedures, specifically device implants without sacrificing quality? So let's give you a little background about our health system here in Delaware. Bay Health is a community health system consisting of two hospitals with around 400 licensed beds split between two campuses, the Kent and Sussex campus. Now, we do have three cath labs at the Kent campus, which is our main campus, with one being dedicated to EP. Now, Dr. Miller, can you give us a little background about how we got to this point where we needed to start doing same-day discharge? Certainly. I came to the Bay Health Medical Center in 2013 to do full-time electrophysiology. At that time, any devices that were done typically stayed overnight, and that was the routine, the standard of care. I felt comfortable with the concept of same-day discharge. I had done it previously, and it had always worked well for me, but it was a minority of my patients. There were no established guidelines at the time, so we took each patient individually and considered whether they looked able to be discharged. The proof of concept was there. The ones we sent home were doing well, but there was no formal protocol, and we sat down and began to establish who should be considered for discharge and who shouldn't. To couple this and kind of add to it, around 2017, we really started to see a bed crunch of OBS beds, where these patients would go to overnight. What was happening was those patients were being held in our pre- and post-interventional space, and that was not well-received by anyone. Patients were not satisfied being stuck on a stretcher in a bay all night. Staff weren't satisfied because they were now being forced to stay overnight with those patients, and we really needed to make a change. So we came together as a group and started looking at the literature. So in order to put this whole thing together, we put together a multidisciplinary group consisting of the EP Medical Director, Dr. Miller, our EP Nurse Practitioner, Deb Warshawski, who was integral in this whole process and its success, our pre- and post-procedure clinical coordinator, our EP Lab Manager, and our Cardiovascular Service Line Director to identify implementation requirements. Now, when we took a look at the literature, there was really little out there specifically related to the efficacy, criteria, and outcomes of same-day discharge post-EP implant. Tests completed analysis of over 1,300 centers and concluded it was feasible to do same-day discharge, but they didn't provide any specific criteria or inclusion-exclusion. So then we looked at a consensus statement from our PCI colleagues to help develop that inclusion and exclusion criteria, as well as the immediate post-op care and the monitoring, and lastly, the follow-up. So who exactly was a candidate for our study for same-day discharge? We sat down and we labeled a set of things that we considered necessary for people to be same-day discharge candidates. They had to be healthy individuals that included younger individuals. We said 85 and younger as the cutoff. If they had any symptoms at all, such as breathlessness, heat-compensated heart failure, if they were on oxygen for COPD, if they had comorbid conditions, such as severe aortic stenosis, if they had active angina or active edema, they were not candidates. If there was anything that they could be tuned up by keeping them overnight, there was value in keeping them and we kept them. Their labs had to be essentially within normal limits and they were elective outpatients. The inpatients were not included in this evaluation. Exclusions, anyone, the procedure had to go well. If there were any issues, hemodynamic instability, any volume overload issues and procedural complications, excess of procedure length time, excessive bleeding, people would be kept for observation. If they had uncontrolled hypertension or diabetes, again, there was value in keeping them and keeping them tuned up. We weren't kicking people out for the sake of kicking them out. We were looking for healthy people that there was no value in keeping them overnight because they were already tuned up and stable. Patient caregiver also had to be available in order for them to be discharged. If they were living home alone, we did not want them having anesthesia than going home and being alone that night. So what was the post-procedure care of our device patients that were candidates for same day discharge? They typically would be either general anesthesia, MAC anesthesia or contra-sedation. Most patients were MAC anesthesia. They would recover in the PACU and then go to same day surgery for the residual monitoring time before discharge. We would do a post-procedure EKG, do a chest X-ray, looking for pneumothorax or any abnormalities and we would order antibiotics, two days prophylaxis worth from the hospital pharmacy that would be delivered to bedside. The patient would then have their prophylactic antibiotics to take home with them. The next set of criteria the group put together was what benchmarks did each patient have to meet in order to be safely sent home same day? Well, each patient had to be monitored in the post-procedure area for at least four hours under telemetry. Their ALGREDI score had to return back to baseline and that's what we use here at Bay Health to score whether a patient is under any more sedation and would be safe to go home. The patient needs to demonstrate the ability to return to their baseline ambulation prior to coming in for their procedure. We have a really great meds to beds program where discharge meds are delivered right to the patient's bedside prior to discharge and those meds could be their antibiotics or their anticoagulation meds that would be prescribed for them. Next, we really put an end time of 5 o'clock to discharge these patients on the same day. Now it was up to the discretion of the physician and the patient in the event that something were to delay their discharge past 5 p.m., but as a general rule, we tried to get all patients out of there before 5 o'clock. And lastly and most importantly, the patient has to have a responsible person at home to stay with them. It really helps them with their safety and our ability to feel comfortable sending them home so someone can bring them back in in the event something were to happen overnight. I do want to take this time to mention Deb Warshawski. She's our cardiac cath and EP lab NP and she was integral to the success of this study. She helped ensure the patients were appropriately selected. She made sure all the orders and anything needed in the post-procedure space was taken care of. And then she really made sure that all the same day discharge criteria was met so that every patient was going home feeling safe and comfortable and their families were comfortable. And without her, we would not have seen the success that we've seen in this program and we really want to thank her for all that hard work she did. So regarding follow-up, we would typically have the patient seen roughly a week for a wound check and device interrogation. This also allowed us to answer any questions and to make sure that their device monitoring program was being implemented appropriately as well. Secondly, the patient would be called on the next business day to assess and document on an outpatient post-procedure call sheet, a questionnaire to just see how they were doing, answer any questions, and improve patient satisfaction. Make sure we were thinking of them and make sure that they were carrying out their directions appropriately. Now I joined Bay Health in late 2020 and I was very surprised to find out that we were sending patients home same day post-EP implant. In my previous experience, we had held every EP implant overnight at least one night. So when I heard this, I wanted to get the data and so I took a look back as far back as we could find clean data in our EMR and this is what we found. I'm going to let Dr. Miller talk through. Sure. Our EPIC data was clean as going back to 2018 and we looked at the five years of data, total of 988 patients, averaging roughly 87% same day discharge. And this was rather consistent over those five years. And once we had a patient population, we wanted to know how were they doing. Okay. As we look at our data, our numbers grew over time and our percentages grew over time and we became increasingly concerned that our numbers of readmissions did not grow. We didn't want to be sending people home that we should be keeping. We gave proper diligence of doing education in the office, education pre-procedure and education post-procedure, as well as giving them issues in writing, things to watch for. What we found was that we had two readmissions or a 30 day readmission rate of 0.2%. The national average was 12%. When we look at our total all cause readmission rate, there were a total of 15 patients representing 1.4 readmission rate. So although we were being aggressive and getting people home, we felt like quality of care was being maintained and we felt good about our protocol and procedure. So why do you think we were so successful, Dr. Miller? I think one of the key things was laying the foundation in the office, setting proper expectations, having proper education so people knew what to expect and keeping it simple. Two days, 48 hours, their top dressing came off. Steri strips would fall off in a week. They could shower right away and otherwise light duty for a month. Those were the key things that we reinforced again and again. We also made sure that the office was available for hematoma evaluation, any oozing, any site check requirements, and that kept people out of the emergency room. And when needed, we placed pressure dressings rather liberally. All of our patients typically were on anticoagulation of some kind, either anti-platelet or antithrombotics, and key protocols for stopping anticoagulation and resuming anticoagulation was a big key to success. And here's my favorite slide, the money slide. The administrator in me just really digs this slide. So as you can see, we had a total savings of 3.29 million dollars over our study time from 2018 to 2022. Now as you can see, each year we generally increased in our savings and that's because we continued to grow throughout this time. We were growing in our program, our patient population was growing, so obviously the more volume we were doing, the more we were avoiding and saving against that. And what we used to calculate this was the cost for patients that stayed overnight versus the cost of patients that went home same day. And obviously you were avoiding those costs. And one of the things that was very difficult to quantify is how we were able to actually help with throughput in the hospital because we were no longer taking up beds that were previously held by our overnight observation patients. But as you can see, this 2022 is annualized to 884,000 because we've only had six months of data up to this point, but if we keep at our current growth rate, we will save 884,000 dollars against what we would have if we were admitting these patients one night per observation. So why is this important? It's important because now we have the ability to reinvest this 3.29 million into other programs, into better supplies, into improving our technology in the lab, and also helping to expand our resources in the lab. So this savings has been very helpful for us in not only proving our concept that this is safe and it is a cost-effective way of sending people home for the health system, but the other piece is to just show that we're actually doing our due diligence and best by our patients. So in conclusion, same-day discharge has been safe in our patient population here at Bay Health. In review of our 30-day readmissions over that four and a half years, the ones that did come back in, none of them had a pocket infection or a delayed pneumothorax. And to really reiterate everything of our results, our patient and staff satisfaction increased with this new process. We only had a 0.2 percent readmission rate or a 0.3 percent 2 percent readmission rate or an all-cause readmission rate of 1.4 percent. And we had a cost savings against the charges of overnight stay versus staying same day of 3.29 million dollars. Now one impact that we did not mention is the fact that during COVID, we already had this process established and hardwired. So that allowed us to continue to serve our patients while others in the area were not doing any elective cases due to bed unavailability. The fact that we had this hardwired and our patients were comfortable with it, we continued to implant during COVID and we did not have to limit those cases. Now Dr. Miller, was there anything that you felt potentially we weren't thinking of or some limits of our study? Yes, I think every study has limits and as we look at the limitations of this study, it's a single center, predominantly single operator data. It's a retrospective chart review and it really just looks at readmissions. The two key things we focused on were over time, what percent of our outpatients were being sent home the same day and as that number changed, were our readmission rates increasing? Were we having setbacks because of it? And I think we answered those questions that a majority of our patients could be sent home effectively and our readmission rate was quite acceptable. This was not a controlled study. We did not look at hematoma evaluation in the office or ER visits who were oozing on the weekend. Those happened and they were seen and released the same day. They did not result in readmissions. The last thing is we did not standardize anticoagulation management. We did have a strategy that was consistent, but for example, someone with a mechanical valve, we might do on their coumadin while someone who has AFib, we would hold the warfarin for one day while someone who has DVT prophylaxis, we might hold coumadin two or three days. So we would individualize, which is not inappropriate, but we did not have that written as a hard protocol for us to follow. So there are ways to look at this in an ongoing fashion. I think holding anticoagulation pre and knowing when to resume anticoagulation post has a lot to do with wound management and risk for readmission. So future considerations in expanding this. We'd really like to expand our case mix to more complex cases like AFib ablation or Watchman cases. We're going to expand our inclusion criteria to more high-risk patients and see how we're doing against that 30-day readmission. And then we want to see if we can make this a little more streamlined and reduce the monitoring time based on select patient criteria. All those three things we'll continue to monitor and hopefully we'll be back in a couple years and we can tell you how we're doing. And with that, that's our presentation. Thank you for spending the time with us today and learning about same-day discharge here at Bay Health and our successes. If you have any questions, you can email either myself or Dr. Miller. Our information is in our bios. And with that, you have anything to say? We appreciate the opportunity to share our data and we're excited about the next step that we have to look forward to. Thank you.

Dr. Raymond Miller

cardiac electrophysiologist

same-day discharge

cardiac procedures

device implants