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A dedicated lounge for uncomplicated cath lab patients led to a nearly a 50% increase in same-day discharges, a single-center study found.

In the first year the lounge was operational, the overall rate of same-day discharge for patients undergoing elective percutaneous coronary intervention (PCI) was 51.2% compared with 2.3% the year before the lounge's debut (P<0.0005), according to Andrew Archbold, MBBS MD, and colleagues from Barts Health NHS Trust, London Chest Hospital in London.

The rate of same-day discharge also increased for patients undergoing diagnostic angiography, from 72.7% prelounge to 84.9% post-lounge (P<0.0005), they wrote in the March issue of the American Heart Journal.

The increase in same-day discharge resulted in an "estimated 595 bed days ... saved through reduced overnight admissions in elective patients," Archbold and colleagues found.

In other words, the radial lounge was responsible for freeing up two to three beds on average per day.

The lounge consists of four units, each with a reclining chair, TV, and access to mobile phones and the Internet. Patients do not wear a hospital gown for the procedure, so they enter the lounge dressed for discharge. The tranquility is not disturbed by beeping monitors or the sight of medical equipment. Emergency supplies are behind a section of the room that is partitioned off.

The aim of the lounge, researchers said, is to "minimize the feeling of 'hospitalization' ... while avoiding the need to access a hospital bed."

The hours of operation are 8 a.m. to 7 p.m., Monday through Friday. If the procedure is uncomplicated, angiography patients leave after a 2-hour stay and PCI patients leave after 4 hours. The lounge opened in July 2009.

The huge increase in same-day discharge for elective PCI was not due to a rise in the proportion of cases (increasing only from 62% to 66%). Nor was it due to patient characteristics that would influence early discharge. Rather the increase "reflected a change in culture at the operator and departmental level away from the expectation of overnight admission to the expectation of same-day discharge," the investigators said.

In the U.K., the use of radial access increased from 10% in 2004 to 43% in 2009, namely because of the lower complication rates compared with transfemoral access.

Interestingly, during those 5 years, radial access was used more in patients with non-ST-segment elevation myocardial infarction (non-STEMI) and STEMI (46% and 42%, respectively) than in stable patients (39%).

Archbold and colleagues said the higher statistics for the higher-risk patients likely reflected physician concern for bleeding in these patients who are given "multiple potent antithrombotic agents."

However, "stable patients ... have the greater potential to benefit from transradial procedures in ways which are not usually applicable to unstable patients," they said. These include immediate hemostasis and ambulation, which in turn increase patient satisfaction.

For the study, researchers reviewed records from July 2008 to June 2009, the year before the lounge opened, and from July 2009 to June 2010, the first year of operation. The mean age was 64, nearly three-quarters were men, two-thirds were Caucasian, and half had been previously revascularized.

In-hospital major adverse cardiac events (MACE) included death, myocardial infarction (MI), stroke, or the requirement for repeat PCI. Follow-up for all-cause mortality went beyond the first year, with a mean of 19 months.

Each interventionalist could choose the access route. In transfemoral cases, vascular closure device of preference was the Angio-Seal.

The total patient cohort managed in the radial lounge was 1,548 -- 1,109 for angiography (84% radially) and 439 for PCI (82% radially).

A total of 97% of the angiography patients and 85% of the PCI patients had same-day discharge.

There was a significant difference in overnight admissions, favoring the transradial patients. For angiography, the rates were 2.8% versus 4.1% (P<0.05) and for PCI, they were 14% versus 20% (P<0.01).

There were no deaths or arrhythmias in the radial lounge for the year of the study. Patients admitted directly to the hospital had a higher rate of arterial complications than those who went to the lounge (3.5% versus 0.2%, P=0.001) but similar MACE rates (2% versus 0.9%, P=0.18). In-hospital patients also had a higher rate of all-cause death (4.2% versus 1.1%, P=0.008).

Researchers observed some differences between patients managed in the radial lounge and those managed in the hospital. The radial lounge attracted a younger crowd, with fewer comorbidities, less complex PCI, and more transradial procedures.

However, as the researchers gained experience with the radial lounge, the bar for admittance was lowered. They now admit all elective PCI patients to the lounge following the procedure, where they will be assessed for same-day discharge or overnight observation.

Patients with renal dysfunction are now able to be managed in the lounge, because "protocols for prehydration and for monitoring of renal function have been changed."

Even patients with prior coronary artery bypass graft surgery (CABG) and those undergoing patent foramen ovale closure are also discharged from the radial lounge.

The study is limited because it's a single-center study, observational, and has a relatively short follow-up duration.

From the American Heart Association:

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