BCIS Autumn Meeting 2008, Stoke on Trent, UK Outpatient PCI BCIS Autumn Meeting 2008 Stoke on Trent,...

BCIS Autumn Meeting 2008, Stoke on Trent, UK

Outpatient PCI

BCIS Autumn Meeting 2008

Stoke on Trent, United Kingdom

Gerrit Jan Laarman,

Department of Interventional

Cardiology, OLVG, Amsterdam,

The Netherlands

Department of Interventional

Cardiology, King’s College Hospital,

London, United Kingdom


Outpatient PCI

Definition of outpatient PCI

= Discharge on the day of PCI


Outpatient PCI

Why not?

Possible reasons:

• Medical• Legal• Financial• Psycho-social/cultural• Other (conservatism, egoism, laziness, stubbornness)


Outpatient PCI

Medical reasons:

• Cardiac complications– Acute stentthrombosis– Arrhythmia

• Vascular complications– Access site bleedings– Other vascular complications

• Other complications


Outpatient PCIThere is no medical need to keep the patient overnightwith an optimal result following elective TRI in wellselected patients, meaning:

• NO BLEEDING COMPLICATIONS

• NO CARDIAC COMPLICATIONS

BETWEEN 6-24 HOURS after PCI

• Laarman et al. A pilot study of coronary angioplasty in outpatients. Br Heart J. 1994;72:12-5.

• Kiemeneij et al. Transradial Palmaz-Schatz coronary stenting on an outpatient basis: results of a prospective pilot study.J Invasive Cardiol. 1995;7:5A-11A.

• Kiemeneij et al. Outpatient coronary stent implantation. JACC 1997;29:323-7• Slagboom et al. Actual outpatient PTCA: results of the OUTCLAS pilot study. CCI

2001;53:204-8. • Ziakas et al. Safety of same day discharge radial PCI. Am Heart J 2003;146:699-

704.• Slagboom et al. Outpatient coronary angioplasty: feasible and safe. CCI

2005;64:421-7.


Outpatient PCI

Legal reasons:

• Efficacy and safety of outpatient PCI has been clearly demonstrated and described in a large series of publications from different groups in the past 15 years.

• In several countries outpatient PCI has become

clinical routine.• Thus, there is no ground for any legal objections

anymore


Outpatient PCI

Psycho-social/cultural reasons:

• Dependent patients• Elderly patients• Insecure patients• Preference for staying overnight

Keep those patients overnight!


Outpatient PCI

Financial reasons:

Macro-economic view

Outpatient PCI using the transradial approach leads to a reduction incosts:

• Shorter hospital stay• Shorter procedures• Less material consumption• Less bleeding complications• More efficient nursing care• Cheaper transportation (no ambulances between hospitals)• Back to work earlier


Outpatient PCI

But:

Micro-economic view

In the Netherlands reimbursement for daycare PCI is

€ 5.500,= and for clinical PCI € 8.500,=


Outpatient PCI

Other reasons:

• “I don’t like changes”• “I don’t trust myself and like to sleep soundly”• “they’re cowboys”• “secundary prevention less effective after easy cases”• “they’re banalising PCI”• “I don’t do TRI because during PCI’s I’m always thinking

about future CABG’s with the radial artery as a conduit”


Outpatient PCI: Rationale

• All the advantages of TRI• Patient comfort• Beds available for sicker patients• Safe• Logistics: OLVG 36 cardiology beds/2400 PCI’s

• Increases turn-over• Reduces waiting lists• Cost-effective


Outpatient PCI

TRI

• From alternative to preferred access site• Easy hemostasis (superficial course)• Less bleeding complications• No important nerve or vein near by• Allows ambulant/outpatient PCI• Patient preference• Cost-effective


Outpatient PCI

TRI especially beneficial in

• Elderly patients• Obese patients• Patients with musculo-skeletal disorders• Restless patients• Patients with severe peripheral artery disease• Patients with ACS requiring triple antithrombotic

medicationNow they can be treated as outpatients as well!


Outpatient PCI


Outpatient PCI

Requirements for outpatient PCI

• Transradial approach• Dedicated infrastructure (lounge)• Dedicated and trained nursing and medical staff• Optimal information before and after PCI• Triage criteria


Outpatient PCI: Criteria

• Good result elective PCI

• No complications during PCI

• Clinically stable

• Uneventful course during 4-6 hours observation

• Cardiac

• Vascular

• No other medical reasons to keep the patient hospitalized (e.g. renal failure)

• Suitable psyco-social circumstances


Outpatient PCI: Current policy

After >15 years experience (1992-2008)

• Elective PCI• ± 60-80% in day care

• UAP [clinical]• Same or next day (IIB-IIIA blockers) discharge

• Inter-hospital: ± 100% transfer same day

• Primary PCI: • Day 3 discharge

• Interhospital: ± 100% transfer same day


Outpatient PCI: Lounge Day Care Cardiology

Atypical chestpain (120: 48 pts for further observation on ward)

Bleeding complications (120 minor bleeds;90 same day discharge): 30 pts for further observation on ward)

Angina without ECG-changes (75: 24 pts for further observation on ward/CCU)

Angina with ECG-changes (18 → CCU) Acute stent thrombosis (2→ cath.lab.) Coronary perforation (3 → CCU) VF in lounge (1 → CCU)

No serious complications reported after discharge


Elective PCI in elderly patientsElective PCI in elderly patientsElective PCI in elderly patientsElective PCI in elderly patients


Outpatient PCI: Conclusion

• TRI allows you to re-design the process of hospitalization of PCI patients

• This lounge-like environment for ambulant and independent patients is the most extreme logistic manifestation of the transradial approach

• This is the leanest, most efficient and most patient-friendly way of working

• Insurance companies should be motivated to reward physicians following this approach instead of (financially) frustrating them

BCIS Autumn Meeting 2008, Stoke on Trent, UK Outpatient PCI BCIS Autumn Meeting 2008 Stoke on Trent,...

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