There is variable adoption in same-day discharge for pacing procedures across Europe. We compared length of hospital stay and complication rates in two cohorts, using a same-day and next-day discharge protocol. Case notes were reviewed for 229 consecutive patients attending our tertiary centre for device implantation to establish the rate of hospital readmission and complications. These comprised 106 patients in the next-day discharge cohort, and 123 from the same-day cohort. All pacing procedures, including cardiac resynchronisation therapy (CRT) and implantable cardioverter-defibrillators (ICDs), were included.
No significant differences were observed between cohorts in age, gender, device indication, device type, procedure urgency or venous access route. Median length of stay post-implant significantly reduced from 1.2 days in the next-day cohort (25th–75th centile 1.06–3.24) to 0.99 days in the same day cohort (0.3–1.3) and from 1.08 days (0.94–1.2) to 0.36 (0.27–0.97), respectively, for the subgroup of elective patients (n=95). Death, complication, and readmission rates were similar between the two cohorts. Morning procedures were associated with shorter hospitalisation. No same-day cohort CRT recipients (n=28) suffered complications.
In conclusion, same-day discharge for pacing (including CRT and ICDs) results in decreased length of stay without increasing complications.
Introduction
In many centres, patients stay overnight after their pacing procedure. Most would prefer to get home quicker, and reduced length of stay would result in healthcare savings. Various centres have reported high rates of patient satisfaction,1 and significant cost-savings with day-case pacing,2,3 although this practice is not widespread. A recent survey,4 revealed variation in practice across Europe with many centres routinely mandating a one or two night hospital stay.
The safety of day-case pacing was described more than 25 years ago.5,6 Since then, the implant rates of both bradycardia (simple) and more complex devices (cardiac resynchronisation therapy [CRT] and implantable cardioverter-defibrillator devices [ICDs]) have increased significantly.7-10 We are not aware of any published data on the safety of day-case pacing for complex devices.
Due to a recent change in our institution’s implantation policy from a mandatory overnight stay to same-day discharge, we were in a unique position to review the efficacy, safety and cost-effectiveness of such a change. We describe a single-centre, retrospective, cohort study, comparing a next-day discharge with same-day discharge for both simple and complex pacing procedures.
Methods
In our tertiary centre, outcomes and complications of pacing procedures were retrospectively reviewed before and after a change to same-day discharge. Pacing procedures were reviewed for consecutive patients for 60 days prior to the change in protocol (next-day cohort) and compared with consecutive patients for 60 days afterwards (same-day cohort).
Data were collected from the cardiology department at the university teaching hospital in Sheffield, UK. In May 2014, a change in operating protocols was introduced, allowing uncomplicated pacemaker recipients to be discharged on the same day as their procedure. All patients were discharged on the same day as their procedure, unless they were medically unfit, had procedural complications, or presented with high-grade block or syncope, where immediate lead displacement would have had significant consequences. All patients attending for device therapy during March and April 2014, and during June and July 2014 were included.
Baseline demographic data, device type and procedural urgency were collected. Pacing and clinical records were reviewed for any 30-day readmission to hospital, early complications of the procedure (pneumothorax, haematoma requiring intervention/prolonged observation, cardiac tamponade, immediate lead displacement), late complications (lead repositioning, requirement for urgent device reprogramming after 30 days) and death. No other procedural changes were made during the period of study.
Both elective and urgent/inpatient pacing procedures were included in the analysis. The inpatient group comprised patients who had been admitted acutely but could not be safely discharged before device implantation. All patients were followed up for four months post-procedure.
Student’s t-test was used when continuous data were normally distributed and Wilcoxon’s rank-sum test when it was not. Fisher’s exact test was used for binomial variables, and Chi-squared used for categorical data. P values <0.05 were considered significant. Calculations were performed with Stata SE 10 for Mac.
Results
Two hundred and twenty-nine patients attended for device insertion, of which, 106 patients were in the next-day cohort and 123 in the same-day cohort. Across both cohorts, there were 56 CRT devices (24%) and 36 ICDs (16%). Just under half of these were elective (n=95, 41%) with the remainder being inpatients. No significant differences were observed between the cohorts in age, gender, status of primary operator, device indication, device type, venous access or procedure urgency (table 1).
Length of stay
In the same-day cohort, 41 individuals (33.4%) were discharged on the day of their procedure, compared with one patient (1%) from the next-day cohort. After the change of protocol, the median time from device implantation to discharge reduced from 1.2 days (25th–75th centile, 1.06–3.24) to 0.99 days (0.3–1.3, p<0.001) for all patients, with the data positively skewed. Taking only elective procedures into account, this reduced from 1.08 days (0.94–1.2) to 0.36 (0.27–0.97, p<0.001) (figure 1). With inpatients, the median time similarly reduced from 1.56 days (1.11–4.57) to 1.25 days (0.99–6.03, p=0.101).
With the new protocol, 54% of our elective patients were discharged on the same day as their procedure. Reasons cited for overnight stay include social concerns (13 patients, 52%), monitoring of bleeding (one patient, 4%), concern regarding lead stability (one patient, 4%), pacing checks (two patients, 8%), inpatient up-titration of medication (one patient, 4%), delay attaining the post-implantation chest X-ray (one patient, 4%) and operator discretion (six patients, 24% – significant inter-operator variability noted).
Implant timing
In the same-day cohort, 22 of 30 elective patients who had morning procedures were discharged later that day, compared with only nine of 27 elective individuals who had their procedures in the afternoon (p=0.002).
In our study period, no devices were inserted outside of 8am to 5pm, but four of 135 acute inpatients had their devices implanted at the weekend. These were associated with a non-significant trend towards longer stays (median 88.4 hours, 25th–75th centile 26.9–196.2) post-implant compared with weekday procedures (31.2 hours, 25.6–123.5) (p=0.59). During the working week, no significant difference was observed relating to the day of the week a procedure was performed.
Complications
No deaths were directly associated with device implantation, and mortality was similar for the two cohorts (table 2). Two patients developed pneumothoraces, and two patients had cardiac tamponade; in both cases this was identified during the procedure and was treated successfully. There were no observed lead displacements within 30 days, although six patients required lead repositioning at some stage after the six-week device check. Overall, complication and readmission rates were similar between the two cohorts.
We reviewed the cases of those patients who were readmitted within 30 days of discharge. In the next-day cohort, three patients were readmitted with unrelated medical problems, and a fourth patient was readmitted four days after discharge with non-cardiac chest pain, possibly relating to bruising at the pacemaker implantation site. Of the 12 patients readmitted from the same-day cohort, one patient was readmitted the day after the procedure with diaphragmatic twitch (dual-chamber device, reprogrammed), and another after 25 days with early device infection. There were no other procedure-related readmissions. Device interrogation in readmitted patients revealed no pacing complications.
We observed a trend that those patients discharged more than two days after their procedure had a higher adverse outcome rate (33%) than those discharged on the day of their procedure (7.1%).
Complex devices
In the same-day cohort, 14 of 28 patients receiving CRT devices and six of 22 patients receiving ICDs were discharged on the day of their procedure. No CRT recipients in this cohort required device reprogramming at or before the routine six-week follow-up. This compares with two of 28 CRT patients (7%) from the next-day cohort, with twitch identified at or before the six-week check.
Financial impact
We examined the potential cost savings available by moving to a same-day discharge protocol. This change reduced the mean post-implantation stay from 1.1 to 0.54 days per elective patient (p<0.001), and from 4.6 to 4.3 days for inpatients (p=0.19). Our institution implants approximately 690 devices per year. A conservative estimate based on these figures suggests the same-day discharge approach could save 280 bed-days over the course of one year. Given an average excess bed-day cost of £275,11 this would result in savings of £77,000 per year in our institution alone.
Discussion
For the first time, we compare two cohorts of real-world patients following device implantation, before and after a change to same-day discharge. Our data demonstrate the safety of this in the setting of expanded pacing indications.10 Additionally, we include complex device recipients whom we have shown can be safely discharged on the day of their procedure.
The new discharge policy did not result in an increased rate of readmission. Interestingly, most of the 12 patients in the same-day cohort that were readmitted within 30 days, had been kept in hospital overnight post-implant due to social reasons or being medically unfit for discharge. Moreover, across both cohorts, complications were more frequent in those discharged later. Such patients are generally frailer with diminished physiological reserve, and, therefore, it is unsurprising that they were soon readmitted to hospital for reasons unrelated to their pacing procedure.
One patient in the same-day cohort was readmitted the day following his procedure with diaphragm twitch from a dual-chamber device, which potentially would have been identified at a next-day device interrogation, though this was identified and treated promptly with device reprogramming.
Overall, complication rates were similar for the two cohorts. In the same-day discharge cohort, no issues were identified at the six-week post-implant check that would have otherwise been highlighted on a next-day device interrogation. Thus, it seems little is to be gained by keeping pacing patients in hospital for the night after their implant.
Elective patients
For both cohorts, the number of inpatient procedures was similar, suggesting a uniform demand for urgent pacing services. However, in the same-day discharge cohort a greater number of elective procedures were undertaken compared with the next-day cohort. This could have been partly due to the extra bed capacity created by the new discharge policy.
We found a significant increase in the same-day discharge rate in those patients receiving their device in the morning. Further study is required to investigate this trend. Nevertheless, institutions aiming to increase their same-day discharge rate may consider moving pacing sessions to earlier in the day.
Few devices were inserted at weekends, and weekend device implantation was associated with longer inpatient stays, though this probably represents illness severity rather than organisational factors. We hypothesised that device implantation on a Friday might be associated with increased length of stay, though our data did not show this. Indeed, except for devices inserted acutely over the weekend, day of the week did not appear to be a factor in determining length of stay.
In the same-day cohort, more than half of elective patients were discharged on the day of their procedure, though some 46% still waited until the following day. This is a lower same-day discharge rate than has been reported elsewhere.1,2 However, we describe an early experience of a new protocol. Often there was a clear post-implantation intention for overnight stay. As a unit, we are considering ways to increase the same-day discharge rate, for example by removing the current requirement for post-implantation chest radiograph,12 and ensuring that discharges delayed for non-medical reasons are better anticipated. Additionally, we expect the discharge rate to increase as familiarity with the protocol increases among ward staff. Eventually, we expect the same-day discharge rate for elective patients to reach 90%, with overnight stay provision only for unexpected medical complications.
Our study was performed in a high-volume tertiary implant centre with 24-hour cardiologist resident on-call (specialty trainee or consultant). This potentially facilitates evening and weekend discharges, which may be difficult to achieve in smaller centres with a non-specialised on-call service.
There was concern among operators that same-day discharge of CRT recipients would fail to identify those with left-ventricular lead micro-displacement causing diaphragmatic twitch in the 12 hours post-implant. Previously, this was detected at the next-day interrogation. We have seen that, even with biventricular devices, same-day discharge is safe, as no patients required device reprogramming for twitch in the six-week period post-device. We accept that this is a small group (n=14) and further work in this area is required.
The reduction in excess bed-days has the potential for significant cost-saving. Moreover, in the UK, day-case surgical procedures are rewarded by commissioning groups with Best Practise Tariffs (BPTs). BPTs do not currently incentivise same-day discharge for cardiac pacing procedures, but this could change in the future.
Limitations
Our same-day discharge rate, even in the ‘same-day’ cohort was low. This may reflect operator caution, particularly in patients in whom the risk of complications was perceived to be greater, which may have biased our results. Nevertheless, we have shown that taking a cautious approach results in low rates of complications in patients discharged the same day.
Our duration of follow-up was limited, however, any difference in complication or readmission rates would be evident within 90 days. Some patients may have been readmitted to neighbouring centres, but with the close links with our secondary care centres, it is unlikely our unit would not have been notified of the readmission. Furthermore, this would have been constant for both cohorts studied.
Conclusion
Same-day discharge for patients attending for pacemaker insertion resulted in a reduction in length of hospital stay and does not compromise patient safety. This may have significant cost-saving implications for institutions. Same-day discharge was more likely following a morning implant. We took a pragmatic approach with a low threshold for overnight stay in patients considered to be at risk of complications. Our findings also applied to individuals with clinical heart failure and CRT devices, though our sample size was small and more work is required in this
regard.
Author contributions
Study design and manuscript preparation: NK, TN. Data collection: TN, AB, JL, RB, PS, JS, NK. Analysis and statistics: TN, AB, NK. Critique: TN, AB, JL, RB, PS, JS, NK.
Conflict of interest
None declared.
Key messages
- A same-day discharge policy for device implantation is safe in a real-world setting
- Patients receiving implantable cardioverter-defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices can also be safely discharged on the day of their procedure
References
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