Hi everyone, my name is Mary. I am so glad you can join me today. I'm from the UC Davis Medical Center and I'll be talking about optimizing elective PCI procedures. Enhancing same age discharge rates for improved clinical outcomes and cost efficiency. So again, my name is Mary. I am a Quality Improvement Nurse Analyst. Been in this role for a little over a year now. Prior to this, I worked in the respiratory step down unit in the surgical ICU and now I'm here. The registries I manage is Cath PCI and TBT so that involves case abstraction, registry management, quality improvement projects, screening reports, all the fun stuff, so constantly busy. If you guys haven't seen me earlier today, I also have a poster about optimizing discharge medications and cardiac rehab in the inpatient setting. So if you have any questions regarding the poster or this presentation today, feel free to come say hi to me after and I'll be happy to answer your questions. So a little about our hospital. So our hospital is a 656 bed acute care teaching hospital in Sacramento, California. We are a level one trauma center serving about 65,000 square mile area that includes 33 counties, six million residents across Northern and Central California. We admit approximately 30,000 patients per year and our ED handles more than 900 visits per year. So we're a pretty busy facility. Our cath lab performs many different procedures, EP, peripheral, TAVR cases, structural heart cases in general, cath PCI cases, but because this is a PCI focused lecture, we perform about 500 PCIs a year and the NCDR registries that we are a part of is cath PCI, LAO, TBT and EP. So what is this project about? So our, a little background. Our hospital didn't really have a same day discharge guidelines to even follow and so historical context, our facility same day discharge rates for elective PCI procedures was around 10% and that's been pretty low and it's been low for many, many years and two key reasonings on why our same discharge rates have been so low is that one, we didn't have a standardized discharge guidelines for elective PCI procedures and two, it's just been a culture because we just facilitate our culture just like we're so comfortable monitoring the patients overnight and then we'll send them home next day. But this cautious approach has led so many missed opportunities to send the patient home same day and resulting in increased healthcare costs and resource utilization. So that's when we knew we wanted to start a project on this. So our goal is to one, establish a same day discharge guidelines that our facility can use. Two, shift practice towards increasing same day discharge for eligible elective PCI patients and three, address performance gaps and capitalize on cost savings. So the methods that we did for our projects is we closely collaborated with our director, our interventional director and our APPs and what we wanted to do for this project and our director was like, well, let's see what the ACC has and we'll kind of go from there and lo and behold, the ACC has a wealth of knowledge and wealth of resources that we can use to follow and just set a foundation for our own facility. After we use the ACC's pathways and guidelines, we kind of created our own guidelines that works well for our facility. After we made that, we educated our APPs and interventional cardiologists, make sure that we're all on the same page on a newly created same day discharge guidelines and after that, we started to track and make sure that monthly reports out to leadership and our interventional director on how we're doing. So this right here is what the ACC has on their website. So the blue circle says non-urgent PCIs, no NSTEMIs, NSTEMIs. Then we move on to the purple column which is the pre-PCI considerations. That includes clinical factors, social factors and staff and system factors. The green column over here talks about the post-PCI considerations. So that includes the clinical factors and social factors and then the orange column talks about the pre-discharge checklist. So did the patient get their required medications? Did the patients get their cardiac rehab referral done or ordered? Is there a follow-up call patient scheduled? Is there a follow-up appointment scheduled? And then were the patient educated on how to monitor their access site and if anything were to happen, do they know how to call 911? So all of this is part of the ACC's pathways and they also have a different view of this as well. Same concept but if you answer no or answer yes, they will suggest to monitor the patient overnight or the patient is safe to send home the same day. So what we did, we took those two slides and we kind of made it to our own checklist that we were able to use and it's just an easier way for our APPs and our physicians to kind of look at this and be like, okay, this patient basically qualifies to go home the same day but in the end, it's always the provider's decision if they are safe to go home same day or not. So this yellow table right here kind of shows our progression and how we did and what we did and how that improved our assignment discharge rates. So we started this project back in 2023 quarter two when we realized 9% is not that great, you know? And so 2023 quarter three, that's when we started to do our research and kind of just have that conversation with our physicians saying, hey, our 9% is very low. Like, are you guys aware of this? And a lot of times they weren't really aware that we were this low. So having that initial conversation was able to go from nine to 14%. 2023 quarter four, that's when we finalized our own facilities guidelines and 2024 quarter one, that's when we started implementing it on our elective PCI patients. So we were able to go from nine to 24% in one year. Now it's not as great as other facilities where their same day discharge rates is 80 to 90%, which, I mean, I aspire to be like that, but going from nine to 24% in a year, just implementing what the ACC already has is really, really good. And another reason why, like, are that some of the barriers that we have that I'm running into lately is that our facility has a lot of CTO cases. We have a lot of complex PCI cases. Our, a lot of patients are living far away. They can't be sent home same day. So those are some of the barriers that we are running into now. So maybe in the future, next year and the next summit, I can talk about how we overcome that. But for now, nine to 24%, pretty good. So in conclusion, did the ACC same day discharge guidelines improve our own same day discharge rates? I would say yes. As shown significant potential to improve same day discharge rates in elective PCI procedures through collaboration and adherence to guidelines, our facility has witnessed a remarkable increase in same day discharge percentage. And moving forward, continued monitoring and improvement of same day discharge rates will remain an integral part of our commitment to delivering high quality, cost-effective PCI services to our patients and communities. As we come to the end of this presentation, I would like to extend sincere gratitude to our heart and vascular team at UC Davis. They've been amazing to work with. Special thanks to Dr. Southard, our interventional cath lab director, whose guidance has been amazing. Thank you to our cardiology interventionalists. One of them isn't here right now, Dr. Atreja, thank you for all your help. Our cardiac support unit are now dedicated members of our data and quality team. Thank you to my manager. She's the one that's been pushing me to send all these abstracts. I wouldn't be here without her encouragement. And last but not least, I thank the American College of Cardiology for providing such accessible and effective resources that we all can use to improve our standard of practice. So thank you, that's my presentation. Thank you. All right. So as you can see, the title of my presentation is very long. We're looking at the, this is a research study that I helped with up in Maine. And it is Outcomes of Post-Percutaneous Coronary Intervention Same Day Discharge of Non-STEM ST Elevation Myocardial Infarction Patients Versus Outpatients. Which interestingly, if you remember Mary's first slide, the goal recommendations from the ACC had that little blue circle that said, not recommended for patients with unstable angina or NSTEMI. So we decided to see if we could test that theory a little bit. And that's what we're going to go over today. So as we said before, my name is Steve Fox. I'm the CAHPS PCI Database Coordinator at Maine Health Medical Center in Portland, Maine. And I thank you guys all for coming. I hope you're having fun in San Antonio as I am. Anybody been down to the Riverwalk yet? No. Well if you go, you can take a boat tour. We had a great time. It's hot here though. A lot hotter than Maine. And moving forward I'm going to say MHMMC to abbreviate the name of our hospital. We just went through a rebranding. And if any of you hospital systems have gone through rebranding, it's quite a lot. And one of the side effects was our hospital has a much longer name now. And in addition to the CAHPS PCI Database, MHMMC also currently participates in the following registries. We do chest pain MI. I've got Sarah Kovacs here. She's our Database Coordinator who does our chest pain MI. STS, ACC, TVT, LAOO, IMPACT and EP device implant. So a little bit of information about our hospital, MHMMC is licensed for 929 beds. It's the largest hospital north of Boston, Massachusetts. It's a multi-campus center and it has locations in Portland which is the largest city in the state, Biddeford and Sanford, Maine. Our CAHPS Lab is a reasonably high volume. We do around 1,300 PCI procedures per year. And in addition to our PCIs and diagnostic cases, our CAHPS Lab physicians and staff perform structural heart, TAVR, MitraClips, PFO closures. And we're also fortunate to have a dedicated high-risk procedure team consisting of a nurse practitioner, PA and two dedicated interventionalists that do high-risk CHIP CTO cases. Our Cardiac CAHPS Lab is housed in a brand-new facility, the Malone Family Tower which opened in June of 2024, so just a few months ago. It features 96 private patient rooms, a 40-bed pre-post-operation area, 19 new OR and hybrid procedure rooms and a significantly expanded sterile processing facility. I also work per diem as a clinical nurse in the Cardiac CAHPS Lab. And it's very exciting to be part of working in a brand-new tower, a brand-new facility. And you know, it's given Maine Health, Maine Medical Center the opportunity to sort of take the next step to try to be a world-class cardiology center. So a little bit about Maine Health, our umbrella organization. It's a not-for-profit integrated health system consisting of eight licensed hospitals in Maine and one in New Hampshire. They offer comprehensive pediatric services. We have an extensive behavioral healthcare network, home health hospice and senior care services. We have more than 2,000 employed providers and approximately 23,000 care members. So Maine. How many people here have been to Maine? All right. Well, we're glad you came. If you haven't been, we'd love you to come visit. It's beautiful up there, especially now. It's a large geographical area about the size of all the other New England states combined. However, comparatively small population of just about 1.4 million. When I was driving in the Uber the other night, I googled San Antonio and the population of this city is 1.5 million. So just a little context there as to what we're dealing with where our hospital is. There's only four hospitals in our state that perform PCIs. We are the busiest in terms of volume. So what that really translates into is we accept a large amount of transfer patients for cardiac care from all over our state as well as the neighboring state of New Hampshire, which leads to a great high volume of NSTEMI and acute coronary patients who have gotten their initial workup at outside facilities who are now being transferred to have their PCI or a left-questioned PCI from a hospital that already may have done a diagnostic or was unable to perform a PCI at their hospital. So how did this all come about? This clinical study came from one of our third-year cardiology fellows, Omkar Bidigeri, super young, smart, motivated guy. And he presented this study as a poster at the SEII scientific sessions in May of this year. So as the cath PCI registry person, I played a fairly large role in the collection of the data for his study. And with his permission, I said, hey, Omkar, can I submit your abstract to the ACC Quality Summit? This was the first time I had attended this. And I said, I think this is something that would demonstrate something that they might be interested in. We were thrilled to be picked for a live session. A little bit intimidating, because I wasn't really expecting that. I was like, oh, hopefully I'll get an e-poster. However, Omkar initially was going to come and present. But he's very busy right now. He's in the process of applying for an interventional cardiology fellowship. So with that and all of his duties at the hospitals, he was unable to attend. So I offered to present his data. So you're stuck with me for 15 minutes. But I hope that I can adequately present the background for our study. So previous work. I'm sure that at all of your facilities, same-day discharge for PCI patients is something that you are working on, you're interested in, or you're being pushed towards because of all of the benefits of it. We had been tracking this for several years. And Simon Vernick, who is one of our interventional cardiologists, worked with the STEMI project manager at the time and our EPIC enterprise people to create a report that would track all of our same-day discharge PCI patients. So what Dr. Vernick does is monthly he gets this report, brings it back to his meetings with the other interventionalists, and reviews this with them. And obviously, being the competitive type of people that they are, I'm sure that there's a lot of ribbing that goes on as far as who's been able to send home the most patients since same-day discharge. With of course the end goal being to continue for this to increase our numbers and maintaining quality care and safety. So a little bit of background for the clinical study. Same-day discharge, STD after elective PCI has been endorsed by the ACC. However, there's very limited data on same-day discharge in the inpatient population presenting with non-SDA elevation MIs. As you can see from the slide that Mary presented, there just hasn't been a lot of study on this. And so what our study team did was we did a retrospective chart review. And it was conducted of patients who underwent a PCI and qualified for same-day discharge at our institution between 2017 and 2023. It included patients with NSTEMI and outpatients, came in for elective PCI. And the identification and outcomes data was obtained using our EM medical record system or EPIC. And of course the NCDR-CAF PCI Registry played a big role in this because this is where the quality data came from. And one other thing that we did utilize was something called HealthInfoNet Main, which you're all probably familiar with. It's a health information exchange because we have multiple health systems within the state. And the theory was that if a patient came from another part of the state, presented after their PCI to a hospital that wasn't within the main health network, that would be something that would get lost for follow-up. So by utilizing the HealthInfoNet, then the physicians that did the bulk of the data work were able to pull these patients. And so the other thing is for same-day discharge for the purpose of this study, Omkar and I had a discussion about this. It was defined as within 24 hours of the PCI procedure. If you look at what's considered a same-day, this can actually vary within the literature. In fact there are some that consider 12 hours a same-day discharge, which is understandable. But however for this, we used 24 hours from the time of the PCI as our benchmark. So what were our methods? The primary endpoint was Major Adverse Events or MAE at 30 days. These are defined as a composite of all-cause mortality, acute coronary syndrome, stroke, major bleeding or repeat revascularization. So these were the things that they were looking for. I'm not a statistics person, however. The statistical analysis was performed via SPSS. They used a general multivariate model and a chi-square analysis. And they considered p-value of less than 0.05 would be considered significant. So the results from the initial study were 562 patients undergoing same-day discharge after PCI included 141 NSTEMI patients and 421 outpatients that were included. Mental access we utilized in 122 of the NSTEMI patients, just about 87%. 341 outpatients, so around 80%, which is as you probably know, around 90% is sort of like the number that we usually tell, especially when the patients come into the lab and they get on the table and they want to know if you're going to ruin our wrist. Because that's one of their big concerns. We usually say 90% of the people we can get up and around. But that 10% sometimes we can't. And we placed more than one stent in 33 patients of the NSTEMI group, just over 20%. And then 160, almost 40% of our outpatients. And there was no statistically significant difference in major adverse events between NSTEMI patients versus outpatients at 30 days, three of the NSTEMI patients versus four of the outpatients. Acute coronary syndrome occurred in one NSTEMI patient and one outpatient. Major bleeding occurred in two NSTEMI patients and one versus one of the outpatients. So you're looking at very low numbers in terms of percentage. Repeat vascularization, we had none with the NSTEMI group and two of the outpatients. And then there were no all-cause death or stroke observed 30 days in either of the groups. So a bonus. Everybody likes a bonus, right. The research team was getting sort of excited about the numbers that they were pulling. Dr. Vernick said to Omkar, why don't you have the guys go back in, see if they can pull out some data with patients with unstable angina. So they went back in, pulled out 64 patients that hadn't presented, ruled in technically for an NSTEMI and re-looked at the data. The radial axis was used in 53 of these patients of just about 80%. So that number stays pretty consistent. In the unstable angina population, more than one stent was placed in 20 of them. There was no statistically significant difference in major adverse events between the NSTEMI patients versus the unstable angina patients at 30 days. We had acute coronary syndrome occurred in one patient. No major bleeding occurred. And there was no all-cause death, repeat, revascularization or stroke observed at 30 days in that patient population. So the conclusions are that post-PCI same-day discharge in select NSTEMI and unstable angina patients does not appear to increase the risk of major adverse events when compared to outpatients. Provided they are selected appropriately, same-day discharge of both NSTEMI and unstable angina patients is feasible and may be done safely. Same-day discharge may have a significant impact on the healthcare economy and should be further studied on a larger scale. This was a good, decent study obviously that had good numbers. But on a much larger scale to help demonstrate this would be beneficial. And Omkar and the team are in the current process right now of submitting the study for publication. And then I just want to give a little acknowledgement to the study team that helped with this. Kyla was our research assistant who did the majority of the statistical analysis. David and Christian really were the workhorses. They're both resident physicians. And they were the ones that actually poured through all this data and were able to pull this out. Simon was the attending physician. Dave Butzel is our cath lab director. And then Rachel is our director of the cardiovascular service line. And so that was a key component to this whole study was that report was already built and that work was already being done to track same-day discharge patients. So when Omkar came to me and said this is something I want to do, it would have been pretty daunting to have to start from scratch with that. I said, hey, I've got a tool already available. I'm going to be able to get you these people. All we have to do is sort of go through the data from there. And thank you again all for your time. Thank you. Here how do I get back to the main screen? I'll close that one out. Okay, great good Again I would start okay, that would be good That's one way, you know, well, I'm getting there here we go The Emphasis that all of you are under to help a drive Quality, but also cost-saving right? That's a huge thing Now we're all looking at the bottom line and these abstracts resonated with two things number one the impact on patients satisfaction scores and then secondly on the opportunity for their health care systems to benefit financially and That's the sweet spot right to keep patients happy, but also have the institution benefit. So Without further ado. Yes. Thanks for the bridge. I needed that. Thank you Very good. So the title of this presentation is improving inpatient discharge process efficiency for patient satisfaction and resident teaching My name is Doug Miller, and I'm the medical director of the cardiovascular inpatient service at Wellstar MCG Health in Augusta Well star MCG is the newest Hospital in the Wellstar system. It's an Atlanta based system and where they're Augusta based academic health center 360 bed hospital tertiary care level one trauma and The unit that we're going to focus on is our cardiology intermediate care unit Which is a 27 bed step-down unit also used for post-op and PCI patients. It's got a high It's got a good nursing to patient ratio and it's been accredited by all these bodies that are shown here and those Accreditations are all current It's a it's important that this is a referral center for our region in East, Georgia, how many of you been to Georgia? Almost as powerful as popular as me. So And a little warmer. So Nonetheless it is a referral center obviously, we're we support many hospitals community hospitals throughout East Georgia and Western South Carolina and so we do patients that we capture within our own envelope But also see a lot of complex referrals for PCI and CTO procedures, etc This is the mix of our most recent report cath lab activity You can see that there are a lot of diagnostic but a fair number of therapeutic procedures as well Which are broken down on the next slide so you can see we do a large number of PCI stent a Fairly large number of PTC a and then the rest are done on the more complex patients So it's a active complex case cath lab within patients and outpatients Non ST elevation ST elevation and unstable angina patients coming to us as well as outpatients for other indications The background of this study is that Prior studies implementing early hospital discharge done by hospitalists in the pediatric ICU and by adult inpatient setting Inpatient hospitalists have reached mixed results. Will Cagle at our institution published a paper in 2023 showing that standardized discharge rounding could improve efficiencies Well burden and colleagues showed that there was no improvement using adult hospitalists. We decided to test the effects of Standardizing our discharge process in our academic health center by asking all ten of the cardiology attendings to prioritize their Discharges to take place between 8 and 9 in the morning as it compared to their typical individual rounding approaches This is a case study in culture change and organizational standardization If you've met one attending cardiologist, you've met one attending cardiologist and in the setting that we're working in here as you'll see We're working with residents we don't have we have cardiac fellows obviously at 15 cardiology fellows, but and cath lab fellows But we're working with internal medicine residents in the intermediate care unit. So it's an interesting mix of Experiences and personalities So we identified three main variables before doing the study diverse adult population at our academic health center Attending cardiologists rounding habits, which were each different and different resident training backgrounds in internal medicine and some other Rotators coming in from radiology anesthesiology as well as their seniorities as PGY 1 through 3 The lean Six Sigma principles we applied towards the ideal state were the same ones that will Cagle applied in the PICU eliminating resources not creating value for end customers identifying sources of variation and Processes needing controls and finally action planning to promote work standardization and controlling workflow We initiated the project after the patient flow steering committee Reviewed it and kicked off that project in January of 2024 for all the participating attendings, residents, nurses, and other support staff that participate in discharge activities. Our outcomes that we predefined before starting the study are shown here. The primary outcomes were discharge including order entry and medication reconciliation done by 11 a.m. in at least 20% of patients, so I'll show you the baseline data, and by 1 p.m. in greater than 40% of patients. We wanted to do discharges within 90 minutes of the discharge order being written, and we wanted there to be no increase in length of stay. We didn't want people gaming the system and increasing length of stay by doing so. We also wanted to increase the utilization of our new discharge lounge, which was currently about 40 patients a month to 60 patients a month. We wanted to increase the discharge, conditional discharge orders the day before to at least 30% utilization. We wanted to do surveys to see the patients and staff and residents' perceptions of what the project had meant for them. At the Academic Health Center level, we thought there were opportunities to help our organization understand that this kind of a change could take place and create organizational learning and knowledge transfer and potentially a broader culture change in the areas of discharge metrics, length of stay, and diversion. So there was a hope at the Patient Flow Steering Committee and the CMO Office that we would be able to broaden this impact to other units. This is a classic process map from a Six Sigma expert, Matt Tyler, in our Operational Excellence Office. And if anybody wants this afterwards, I'll be happy to send it to you. But this is breaking down every possible step of what's going on between 8 and 9, 9 and 10, 10 and 11 leading up to discharge. It's a combination of activities by attendings in blue, by nursing staff in green, and by residents in red. And you can see it's clearly collaborative and it requires that everybody work together and be highly coordinated. One hour of intensive coordinated activity takes place between 8 and 9 to make this all possible. You can do whatever you want between 8 and 9. You can do whatever you want after 9. I would continue rounds. But between 8 and 9, the residents and the nurses have to be highly coordinated and focused on the actions necessary for discharge to take place that morning, ideally before 11. So once again, broken down as a good Six Sigma person would do. So the results are going to be shown on the next three slides in the same format. We have the endpoint, for example, discharge by 11 a.m. You can see at the upper bar graph the adult hospital performance overall in 2024. You can see the performance in our intermediate care unit, the next bar graph in 2023. And then you can see the performance in the project since it was initiated in January. Also you'll see the updated data since the abstract was accepted where I'll give you updated numbers for the last quarter of our performance going forward after the abstract was accepted. For discharges by 11 a.m., the adult hospital in 2024 was at 10%. The year before in our unit it was 8%. At the time of submission in the intermediate care unit with the new process it was up to 13%. Update on that, you can see that the hospital is still at about 9% and we're now up to 18% of our discharges overall taking place by 11 a.m. So we've gone from essentially 8 to 18% in the course of one year. Those are two-year numbers. Nothing's perfect. Discharges by 1 o'clock appear to be a bit more achievable. You can see that overall in the hospital it was 27% in the prior year. In our unit it was 25% in the corresponding quarter. And in the current analysis at the time of the abstract submission it was 35%. The updated number shows we have actually met our metric of 40% in the most recent quarter of updated data. The hospital still remains at 23%. So selective improvement in one unit while the hospital remains kind of doing the same thing, interesting and an opportunity for sharing information. The next slide, discharges in 90 minutes or less. Adult hospital 32%, our unit previously 33%, with the project in place 46% at the time of submission. So we'd exceeded our target at that point in time. The updated data for the hospital, 33%. We slipped back a little bit to 39% in the most recent quarter. Newhouse staff, right? Newhouse staff. That's what that is. So in any case, we are pleased still with that metric. Average length of stay. So the Chairman of our Department of Medicine said, well, I know what's going to happen. You're going to game this so that people stay an extra day so they can be discharged efficiently the following morning. And I just bet that's what's going to happen. And we showed him he was wrong. You can see in the overall hospital our average length of stay, 6.5 days. At the unit in the previous year it was 6 days, which was at the target. But in the study as we submitted it, it was 5.7 days. And we're now down to 5.4 days. The hospital has overall come down a little bit to 5.7 days. But you can see that we're continuing to improve our length of stay as a result of this project. Finally, discharge order entry by 11. In the previous year 28%. We're now up to 39%. We're not quite at our target at that point. But now in the updated data we're at 45%. So we've beaten our target that we predetermined. So in every single one of our metrics we've either been at or beaten the target. And we continue to get better as we go along, which is a good sign. Because the hardest part of this, as you know, is sustaining it in a continuous basis, right? Surveys show that in general, and we don't have all the data collected yet, so I didn't want to end with that game show, survey shows. Survey shows that nurses are happy with this project. It adds standardization to their workday. There's a push to get people out by 11. But there's no question that they are glad to know who's being discharged as early as 8.15 to 8.30 in the morning. That process of meds to beds and all the things that people have to do can get underway. We do use the discharge lounge if we need to, if people aren't ready to go at the door by 11. So that's an enhanced use of the discharge lounge. The residents are happier. We're now introducing other ways that they can participate in this and be active advocates, if you will, within the training program. And I think the attending physicians, who I thought would push back hard on this, actually have kind of accepted it. I've had to go in and talk to some of them. As a former dean, I'm used to going in and giving people guidance, we call it. But in any case, it's been, I think, generally well received. And we have data that we'll put together, hopefully can share with you. So conclusion, AHC inpatient flow does present numerous discharge performance improvement opportunities. The Lean Six Sigma processes used by pediatric hospitalists in our PICU were successfully used by attending cardiologists in an adult hospital intermediate care unit. Measurable discharge process improvements towards an ideal state were achieved without length of stay gaming. And finally, sustained customer benefit or value creation requires continuous process reinforcement, meaningful stakeholder engagement, and organization-wide learning. As we take the project forward, we have new goals for 2025. We would like to help export this process to another unit that isn't quite the same as ours. We're working on that. We are also working on increasing the use of conditional discharges. I don't think we're at 30% yet. That was our target. But we're about 20%. We want to improve upon that. And we finally want to be sure we're staffing in appropriate ways for continuous process improvement given a different process. So if you staff the way you used to staff for your old process, then you're not staffing probably ideally for your new improved process. I want to thank all the people on this slide. Amy Sims is the head nurse on the intermediate care unit. Matt Tyler is our operational excellence guru. Pasha Schaffer is our chief quality officer. Brooke Duncan-Meyer is our service line director, and myself as the physician involved. I also want to thank Dave Blomquist, who is here with us today from WellSTAR, who introduced us to this conference. First of all, we'd never been here before, and it's a wonderful conference. And secondly, who's been an advocate for projects like this, which we presented in an early phase at his quality meeting at WellSTAR in Atlanta earlier in the year. So I want to thank Dave for his strong support. Thank you. »» Thank you all. All right. Now we have a lot of questions. Let's begin. First question is, and this is for you, Steve. What was your selection criteria for appropriate NSTEMI unstable angina? »» So basically the criteria that OMCAR and the research team did, they had a risk model that they used. I'm not intimately familiar with. But it was, they factored in things like the patient's EF, other core morbidities, the patient, you know, they looked at the, you know. So basically it was a patient that would be what we would consider a stable NSTEMI. Also part of that was, did they have a safe discharge plan? I think the idea of the lounge, as mentioned, is a great idea because you have patients that are ready to be discharged that aren't, you know, quite, it's a big state as I mentioned before. But that was basically the behind that was, if it was a stable patient in terms of their core morbidities and also the complexity of the procedure. We have patients that come in as outpatients. The CHIP CTO patients aren't going home as a same-day discharge patient. Regardless of how well the procedure actually went, they're all staying over to be seen. »» And also to you, do you know what the median length of stay was prior for the PCI for NSTEMI patients? »» Yes. So roughly 2.1 days. And we're trying to not only work, this is sort of spearheading that, but we're not only trying to work on improving the same-day discharge for our PCI patients. But what this has done is, this has brought up bigger conversations about lengthening, shortening our length of stay for our STEMI patients. Because this sort of, when you start these initiatives and you start moving down this road, they said it opens up the other door. So that's one of the things that we're trying to work on. Right now our length of stay for an uncomplicated STEMI is three to four days. And so they're looking at our data to say, what's the barrier to shortening that as well? But just about 2.1. »» And I believe this is for you as well. Are the patients admitted as inpatients or observation? »» So the patient, that is a great question. Both is the easy answer. So the majority of the patients that were selected for the study were patients that came from other facilities. For example, we have a Catholic hospital, a small hospital in our city, so five minutes away by ambulance. They have a diagnostic cath lab. Those patients in a lot of cases could come in. And we get those patients early in the day. And as you all know, the overarching theme to all of this is do you have the availability to get the patients into your lab? The struggle is real with that. As you see our numbers, even though we got this nice new cath lab in this nice new tower, we are struggling with staffing along with everyone here. We have travelers filling a lot of our roles. So being able to get these patients to the lab is the number one thing. They don't get their case done. We can't discharge them. So yes. »» And then also to you. »» Come on, guys. »» Well the questions came in kind of in order of presentation. »» That's okay. I'm just kidding. »» So it's all good. Did you see an increase in missed MI discharge metrics, echo meds, cardiac rehab? »» No, I mean basically the, since it was a retrospective study, you know, they went back in and they looked and we didn't, in other words, you know, are we missing things because we're trying to get these patients out the door? I will tell you that the care, the standard of care, these patients all had echoes. They all had had troponins that had flat lined or were, you know, very low. And so the appropriate discharge medications, you know, obviously some patients slip out, but that's in any setting, in any. But as far as retrospectively looking back on it, we, you know, there was no, because the study was retrospective, you know. I think you could run into some issues if you were going to do this in a prospective study where you challenged to say this is something that we want to do and we really want you to try to get these people out the door. Maybe that would flip the narrative a little bit and then you might run into that. But retrospectively, no. »» Okay. And Mary, does the time of day play into account, as in what time is too late for a discharge? »» So our facility, we made a cutoff point of 5 p.m. Well technically, it would be midnight would be like the same day discharge of what we counted. But we oftentimes send home our patients. If they are coming out from a cath lab after 5 p.m., they're going to be most likely staying home. So our goal was if they came out of cath lab before 5 p.m. and there's no complications, they had a pretty easy PCI procedure, then they would qualify for the same day discharge. »» And Doug, Dr. Miller or Donald, which do you prefer? »» Doug. »» Okay, Doug. »» For you. »» Okay. »» Does your team utilize APPs to manage, coordinate and streamline the discharge process? »» No, we don't in the inpatient setting. We have APPs assigned to the cath lab to improve upon aspects of that as others have. But we have a resident-driven program. And the interesting thing about our acquisition by WellSTAR is that this is the first big hospital where residents and attendings instead of APPs perhaps and attendings are interacting in this service. We have other services or hospitalists that are APP and hospitalists working together. But we don't have them involved in this service at all, no. »» And after attending the session on meds to beds, when did patient education on DAPs and medication compliance take place? The discharge within 90 minutes seems like there's an opportunity for a gap. »» So meds to beds, education and other activities related to the post-discharge management of the patient, medications especially, take place in that period intensively between 830 and 11. There is knowing that the patient is being teed up the day before for discharge at 4 p.m., a lot of those things can begin and the pre-work that can be done there creates an efficiency. That's why we're trying to really increase the conditional discharge utilization to the higher level. It is a symmetry between the two that works the best. And the point I guess I should make in a session like this is that the more you can move people out of the hospital efficiently, the more beds you have, or your referral PCIs and other referral cases, it creates an efficiency there as well, which is I think worthy of noting. Our length of stay obviously includes heart failure patients, it includes other patients with other cardiac conditions. So it's longer than the typical PCI patient. But it does, they interact in that kind of a unit where there's different types of patients on the service. »» Also to you, how was your discharge lounge perceived by patients and staff? »» That's been an interesting, pleasant surprise. It is nicely laid out, individual chairs for people, televisions, salty snacks, no just kidding. It's almost like an airplane. But no, it's been very well perceived because we do have people that have to be picked up from two, three hours away. It's hard to get a family member into the hospital by 11 a.m. in the morning. So it's become a very good play. The staff from the discharge lounge are happy to come up to the floor and help to take the patient to the discharge lounge so that the nurses on the floor don't have to be tasked with that in addition to getting the discharge done. So it's been a wonderful addition. It's kind of like, where was it all of our lives? I don't know, but it's good now. So we're glad for it. »» Mary, according to the ACC expert consensus, a same-day discharge is defined as a stay after a PCI procedure that does not include supervised overnight monitoring in the facility and or the hospital. So were you all measuring the 24 hours or the day of the procedure? »» The day of the procedure. So let's say the patient had a PCI done today, then midnight would be our same-day discharge point. »» So in cath PCI we measure same-day discharge in some of our metrics, right. So it's a 24-hour day actually after the procedure. So if they're overnight, then the 24 hours ends the next calendar day. »» I have a way for you to improve your numbers. »» Yeah. »» 24 hours. »» Yeah. Right. Because it's the, and then I think you can put them in observation and there's some billing incentives for that, right? Steven? »» Yes. »» What report did you build to track the data? »» I guess the data for, the report, well there was multiple reports. The first report was an enterprise report that was built by the people in Epic. And that report was basically identified the same-day discharge patients. As far as to track the outcome data, we used the cath PCI data because those were all, so basically, you know, those were, and when the physicians went in and looked at, if they saw a readmission for a patient that had had the PCI within 30 days, then they would look and see what was, was it because of a bleed? Did they have to come back in and get a new stent? Did they have an ACS or an AMI? Yes. And the impetus behind this was the overarching thing like I said during the presentation is we all are striving to get patients out of the hospital quicker to create space for patients that come in. I think the idea of the lounge is great. What we had to start doing during our surges were patients that were ready to go home are being put out in the hallway. Or they take lounges at the end of the floors that were normally for families and they put beds in there or chairs and the patient sits out there and waits for their ride. So I think something like this is great. »» There was, when I was still in the ER and we were struggling for beds all the time, I would have welcomed these initiatives. And I found an article called, Your Hallway or Mine? And I used to take it to the bed control meeting and be like, guys, here, read this article. Because our ER was full of hallway patients, right? So decompressing the units helps many. There's a trickle-down effect to all the units it helps. »» One other thing I'll say about that, because I thought about that when you mentioned that paper and then went to our patient flow steering committee meeting, is we're entering into a compact with our ED to provide exceptional responsive cardiovascular consultative and testing services in the ED so that they don't clog up with our patients. And now that we've created capacity, we can actually take that as a next step so that when they ask for a consult, it's done within an hour. If they ask for an echo, it's done within an hour. We can move people forward in a manner that is highly efficient. And you couldn't really have done that until you understood your discharge and flow process. So now that we understand that, that idea of a compact between service lines, cardiovascular emergency services will hopefully take it to another level and get patients out of the hallways. »» Yes. And when the ER's overburdened, the only way to really impact or decompress the ER is to cancel elective cases. And nobody wants to do that either. So it's a tricky balance. It's a game of chess, you know. So it's great when everybody, I think what your project demonstrated is how well you can get a whole group of people across the teams to work together. Okay. So Steven, back to you. Was all of your 30-day adverse event tracking able to be auto-pulled from the EMR or was there some manual abstraction component? »» So it was all auto-pulled from the EMR. And then also, I guess you could say somewhat manual extraction. Because when we did find a patient that had showed up at a hospital that was outside of the facility that wasn't, coincidentally the hospitals that aren't in the main health network that are on HealthInfoNet don't use Epic. So it's kind of a combination. The other bigger hospitals especially are not universally. So it was like a combination of those two. But manually abstracting that data from the HealthInfoNet. Otherwise, the majority of the patients returned either to our facility or to a main health because we're spread throughout the state. So the majority of them that returned to a hospital that was within the system. »» And Mary, what was the distance or drive time that a patient needed to live in proximity to your facility or any other acute facility to qualify for same-day discharge? Was that part of the equation? »» That was not part of the equation. But we are running into, we're looking at our patient population and how many miles they do live. And we have a good amount of patients that live 10 miles away, up to like 60 miles away. And we've had an issue with all of these patients that live in any kind of miles. So we do have a contract with Lyft and our Marriott Hotel that's really close by to our hospital. But we just haven't had an implementation process quite yet about, you know, sending home our patients, or sending patients to the hotel, or if they don't have a ride home they can use Lyft. So we're going to continue working on that and hopefully that will improve our numbers as well. »» And one more question for you. Has there been any resistance from the attending to send patients home on the same day? And what do you do to convince them? »» Oh, absolutely. I mean, like I said, as a coacher, they're so comfortable keeping their patients overnight, monitoring them especially. But we do have some physicians where they do only just perform CTOs, they only perform complex PCIs. And those are the physicians where I don't really even bother. But they do challenge themselves and they're like, well, this patient was, even though it was a CTO, it was completely stable. And the procedure was early enough that they could monitor a good amount of time throughout the day and they do get sent home the same day. So it is possible. I think just having that conversation continuously and showing them the data and showing us how we're comparing to other hospitals and saying that it's working for these other hospitals, these other universities, why can't we be the same? So having that conversation with them and kind of just challenge them. And obviously they want to be able to bring in more patients throughout the day as well. So I think just constantly talking about it to them helps. I just was going to comment on that, if I might. It's sort of a difficult issue because as I watch our interventionalists care for our patients, they really want to see them the next day and say goodbye. And the patients really want that. And you interfere for good reasons with that if you have somebody leaving at 11.55 p.m. And they haven't really seen their physician before they left the door. That security that comes with that is complicated. So I mean, that's an observation. That's kind of what you can do versus what you should do kind of thinking. But I just mentioned that because it's interesting to me how close this is almost to a surgical interaction, right? They really want to see their proceduralists. One of our interventional cardiologists did mention to me when I was talking to him about discharge is that he was concerned mostly because we don't have a really robust way of following up with our patients after they get discharged. Because our coordinators, we're already swamped with so many different things. And our physicians were just, you know, weary that we're sending home these patients the same day, but we're not even having a good way of following up with them over the phone within a good amount of time. And they said that once we were able to fix that, they'll be more comfortable sending home their patients the same day. So that's something else we're going to be starting to work on as well. »» Okay. Doug, two questions for you. We're almost at time. So number one, how is the Discharge Lounge staffed? And then did the patient satisfaction scores for the hospital or your unit fluctuate with the initiative? »» The Discharge Lounge is staffed with three nurses who are there to support post-discharge patient care. There's other staff that are there to keep it clean and kind of keep it organized. It's I think five all together that are there at any one time. And it's I think got 30 chairs in it. So it's a pretty big unit. »» It's pretty big. »» Pretty good size. It's used by other services besides ours and they're marketing it. Other question was? »» Survey scores. »» Survey scores. Our survey scores have always been high. And other than one month where there was a weird decline, I'm not sure what it was, they've either gotten higher or stayed the same since this was initiated. So the patients seem to be accepting of it. And the scores, the satisfaction overall is about 85%, which is quite good. We haven't seen any bump. In the PICU it was interesting because patients wanted to know when their babies were going home. And there was a huge amount of satisfaction with the security of knowing when baby can go and kind of plan your life. For adults, eh, you know, going home, it's fine. It's you know, we're going home. »» Okay, Stephen. Was there a difference in bleeding risk other than MAE between the femoral and radial? »» No. I don't know exactly, I don't know specifically the bleeds that did happen, which there weren't very many. Whether it was a femoral or a radial access. »» Like three, wasn't it? »» Yeah, the bleed, yeah, the number was like three. So I will say that our radial access is just as you saw in the study, just about 80-90%. But I don't know specifically. But one thing that has spurred this discussion today has made me think of now is that an area of research opportunity might be to look at same-day discharge for high-risk CHIP cases. And maybe that's something, an area we've got to look at, because you brought up some great points. Early in the day, reasonably routine as much as it can be for a CTO. But patient goes throughout the day, doesn't have any complications, being able to send them home the same day, that's a great opportunity. »» We measure same-day as procedure. Are you saying that is wrong and it should be 24-hour timeframe? No, it's not wrong. It's just a different metric, right? So same day can mean the same calendar day, or it can mean within 24 hours of the procedure. So there's, you know, it just depends on what your goal is. »» When I looked in the literature, my first thing, I was like, what am I going to be talking about same-day discharges to a group of people? What is a day? It seems silly that you have to define that. But it's important. And it differs. »» Yeah, it differs. All right. We're pretty much at time. I'm going to let you all go. Thank you so much to our panelists. »» Thank you.

elective PCI

same-day discharge

clinical outcomes

cost efficiency

standardized guidelines

patient safety

NSTEMI

discharge efficiency

healthcare costs