key: cord-0756985-1pc0r0f8
authors: Marbach, Jeffrey A.; Alhassani, Saad; Chong, Aun-Yeong; MacPhee, Erika; Le May, Michel
title: A Novel Protocol for Very Early Hospital Discharge following STEMI
date: 2020-08-22
journal: Can J Cardiol
DOI: 10.1016/j.cjca.2020.08.012
sha: 51cc0a0bf9427689dda4592b7d14bb161e68f364
doc_id: 756985
cord_uid: 1pc0r0f8

Although the incidence of ST-elevation myocardial infarction (STEMI) is on the decline, management of patients presenting with STEMI continues to require significant healthcare resources. Earlier hospital discharge in low-risk patients presenting with STEMI has been an area of focus in an attempt to reduce healthcare costs. As a result, discharge within 48-72 hrs following successful primary PCI has increasingly become routine practice. Moreover, the current COVID-19 pandemic has led to enormous pressure on healthcare systems to find ways to increase bed-capacity, preserve resources, and reduce the risk of exposure to patients and healthcare workers. In response to this goal, the Ottawa Heart Institute has developed and implemented a novel Very Early Hospital Discharge (VEHD) protocol. The VEHD protocol is a simple, four-step algorithm designed to accurately and efficiently identify low-risk STEMI patients that can be safely discharged between 20 and 36 hours after successful primary PCI. Once deemed eligible for VEHD pre-discharge tasks are completed by the treating medical and nursing team and the patient is discharged home. Follow-up is completed remotely via through virtual care (48-hours, 7-days, 30-days), and in the outpatient cardiology clinic (4-6 weeks). Amid a worldwide COVID-19 pandemic we believe the VEHD protocol is a crucial step in maintaining exceptional quality of care, both in terms of patient satisfaction and clinical outcomes, while concurrently lowering the risk of nosocomial infections, and reducing resource utilization.

In response to the COVID-19 pandemic the Ottawa Heart Institute has developed a novel very early hospital discharge protocol for patients admitted with STEMI. To preserve resources and reduce the risk of exposure to patients and healthcare workers, this four-step protocol identifies low-risk patients that can be safely discharged between 20 and 36 hours after successful primary PCI.

J o u r n a l P r e -p r o o f Abstract:

Although the incidence of ST-elevation myocardial infarction (STEMI) is on the decline, management of patients presenting with STEMI continues to require significant healthcare resources. Earlier hospital discharge in low-risk patients presenting with STEMI has been an area of focus in an attempt to reduce healthcare costs. As a result, discharge within 48-72 hrs following successful primary PCI has increasingly become routine practice. Moreover, the current COVID-19 pandemic has led to enormous pressure on healthcare systems to find ways to increase bed-capacity, preserve resources, and reduce the risk of exposure to patients and healthcare workers. In response to this goal, the Ottawa Heart Institute has developed and implemented a novel Very Early Hospital Discharge (VEHD) protocol. The VEHD protocol is a simple, four-step algorithm designed to accurately and efficiently identify low-risk STEMI patients that can be safely discharged between 20 and 36 hours after successful primary PCI.

Once deemed eligible for VEHD pre-discharge tasks are completed by the treating medical and nursing team and the patient is discharged home. Follow-up is completed remotely via through virtual care (48-hours, 7-days, 30-days), and in the outpatient cardiology clinic (4-6 weeks).

Amid a worldwide COVID-19 pandemic we believe the VEHD protocol is a crucial step in maintaining exceptional quality of care, both in terms of patient satisfaction and clinical outcomes, while concurrently lowering the risk of nosocomial infections, and reducing resource utilization.

J o u r n a l P r e -p r o o f Cardiovascular disease (CVD) is the leading cause of death in North America. Although the incidence of ST-elevation myocardial infarction (STEMI) has been declining for several decades, STEMI still represents up to 40% of acute coronary syndrome presentations. In addition to a decline in the incidence of STEMI, there has also been a steady reduction in life-threatening complications and death. Most recently, the SAFARI-STEMI randomized trial reported 30-day mortality and major adverse cardiovascular event rates less than 1.5% and 4%, respectively. 1 Regional STEMI systems of care, early reperfusion with primary percutaneous coronary intervention (PCI), and guideline-directed medical therapy have all contributed to this progress. 2,3 Nevertheless, providing care for STEMI patients from the time of presentation until hospital discharge is typically associated with significant healthcare expenditures. 4 Given these important healthcare expenditures -combined with improved patient outcomes -clinicians, researchers, and administrators have increasingly sought earlier hospital discharge (within 48-72 hours) in low-risk patients admitted with STEMI. While same-day discharge following elective PCI in patients with stable ischemic heart disease is common practice, the precise timing of safe hospital discharge in patients admitted with STEMI remains somewhat controversial. This is due to the relative paucity of data to guide clinical practice. At our center, low-risk patients admitted with uncomplicated inferior STEMI are routinely discharged 48 hours after presentation. This practice is supported by the results of a recent metaanalysis -including over 1,500 STEMI patients treated with primary PCI across five randomized studies -which found that there was no increased risk of mortality or hospital readmission among patients randomized to an early hospital discharge strategy (24 hours to 3 days). 5 Furthermore, the median length of hospital stay in the aforementioned SAFARI-STEMI trial was 3 days, with minimal complications following discharge. 1 protocol, which aims to reduce hospital length-of-stay and free-up limited hospital resources.

( Figure 1) The goal of the VEHD protocol is to accurately and efficiently identify low-risk STEMI patients that can be safely discharged between 20 and 36 hours after successful primary PCI. The algorithm was developed based on studies assessing clinical events in STEMI patients following early hospital discharge. 5 Eligibility is determined through assessment of demographic and clinical variables at the time of admission, procedural criteria, and post-procedural clinical parameters. Inclusion criteria were chosen based on the recommendations for early hospital J o u r n a l P r e -p r o o f discharge from the European Society of Cardiology, as well as from previously validated risk stratification scores. Before implementation, the algorithm was validated using the UOHI STEMI database. Briefly, amongst a total of 4,399 patients referred for primary PCI between 2004 and 2015, the rates of in-hospital death or major cardiovascular events (MACE) -a composite of death, reinfarction, or stroke -were 5.1% and 6.9%, respectively. When applying the VEHD algorithm, the rates of death or MACE were, predictably, much lower in the remaining 1,721 patients (39.1 %) at 0.29% and 0.70%, respectively. In this very low-risk cohort, only one patient died within 30 days of hospital discharge. The median length of the index hospital stay was 4 days for the entire group vs. 3 days for the very low-risk group.

The VEHD protocol is a very simple four-step system designed to ensure safe discharge home with all necessary guideline-directed medications, adequate pre-discharge education, and appropriate outpatient follow-up.

Step 1 begins with ensuring that the patient meets all required eligibility criteria as detailed in Figure 1 .

Step 2 involves enrolling the patient in the VEHD program and completing all of the pre-discharge tasks. Specific pre-discharge tasks are assigned to either the attending physician/primary medical team or the patient's nurse. Once all of these tasks have been completed and signed-off in the electronic medical record the patient can be discharged home. In step 3 a trained telehealth nurse will perform follow-up phone calls with the patient at 48-hours, 7-days, and 30-days after discharge to assess for post-procedural complications, confirm medication tolerance/adherence, counseling, and answer questions.

Finally, in step 4 the patient will complete the VEHD program through an outpatient clinic visit -either in person or virtually -with the interventional cardiologist who performed the procedure. All patients enrolled in the VEHD program are prospectively followed until the time of their cardiology clinic visit as part of a quality assurance initiative.

J o u r n a l P r e -p r o o f current methods for delivering care, and in many cases have revealed inefficiencies in our current systems. While the COVID-19 pandemic was the impetus for introducing the VEHD protocol, the available literature, in addition to our initial data, suggest that this change may enable clinicians to maintain exceptional quality of care -both in terms of patient satisfaction and clinical outcomes -while simultaneously lowering the risk of nosocomial infections, and reducing resource utilization. 

Safety and Efficacy of Femoral Access vs Radial Access in ST-Segment Elevation Myocardial Infarction: The SAFARI-STEMI Randomized Clinical Trial

A citywide protocol for primary PCI in ST-segment elevation myocardial infarction

Reduction in Mortality as a Result of Direct Transport From the Field to a Receiving Center for Primary Percutaneous Coronary Intervention

Cost implication of an early invasive strategy on weekdays and weekends in patients with acute coronary syndromes

Safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction: A metaanalysis of randomised controlled trials