Same-Day Discharge for EP and CIED Procedures: A Boon in the Era of COVID

High case complexity and the potential for serious complications have historically dictated a corresponding degree of caution in the approach to invasive cardiac implantable electronic device (CIED) and electrophysiology (EP) procedures, including prolonged patient length of stay. The new burdens placed upon healthcare infrastructure by the COVID-19 pandemic have further compromised the delivery of these procedures for almost all institutions worldwide. This article aims to share our approach and experience of using a same-day discharge (SDD) protocol, which has been crucial in allowing us to maintain high levels of activity in our catheter laboratories and pacing theaters despite the COVID crisis.

Even prior to COVID, increasing financial and service pressures on the publically funded National Health Service (NHS) of the UK have driven the development of more efficient models of delivering care. Within the sphere of cardiac rhythm management, SDD has been an important evolution in achieving this.

Our institution is a dedicated cardiac tertiary center serving approximately 2.4 million people in the North West of England. Since 2014, we have been offering SDD to select patients undergoing CIEDs and complex ablations, and over time, our unit has become progressively aligned to an overall goal of achieving SDD when possible. Minimizing a patient’s time in hospital is a central part of our institutional policy, and this is reflected throughout the patient journey and their interactions with our service. By comparison, a recent voluntary international multicenter survey indicated that SDD was implemented in less than 50% of European centers, even for procedures typically perceived as low risk, such as cavotricuspid isthmus-dependent atrial flutter or supraventricular tachycardia ablations.¹

At the time of entry onto a procedural waitlist, the referring clinician must document whether SDD is considered likely or not, alongside clinical details indicative of the anticipated procedural complexity. In EP, these would include the presumptive arrhythmia diagnosis and the need for 3D mapping; for CIEDs, it would include the use of dual antiplatelet therapy or the need for right-sided venous access. This data is collated by administrative staff through an entirely electronic system, allowing easier planning of theater schedules and required resources.

All patients are formally pre-assessed prior to admission. During this appointment, they are informed of pre-procedural instructions and the logistics of arrival. This in particular helps the patient to understand their expected trajectory on the day of their procedure (an example for atrial fibrillation [AF] ablation is provided in Figure 1). Patients undergo standard blood tests, and are swabbed to check for microbial colonization with significant pathogens (usually methicillin-resistant staphylococcus aureus/MRSA in pre-COVID times, and COVID+MRSA currently). Decolonization treatment is provided if required. These steps allow appropriate order of listing and ward allocation in advance of their procedure.

On the morning of their procedure, patients who are expected to require an overnight stay are admitted to usual ward beds, but the majority attend our dedicated day-stay unit. Arrival times are staggered between 08:00 and 11:00, with the first patients entering procedural theaters at 09:00. A dedicated real-time electronic scheduling system for EP (CareCube, CareCube Solutions Ltd.) reduces the likelihood of overbooking operators, and allows the unit to proactively respond to issues which threaten the running schedule, such as reallocation of a delayed case to an alternative theater.

We favor a light conscious sedation (CS) approach using opiates and benzodiazepines whenever possible including for all CIED implantations, cryoballoon AF ablation, and very high power short duration radiofrequency ablation, obviating the need for neuromuscular blocking agents associated with general anesthesia (GA) that would otherwise prolong the recovery phase.² During EP procedures, ultrasound-guided vascular access has been proven to significantly reduce complications,³ and represents the standard of care at our institution. Other core components driving the logistics of our ablation approach are summarized in Figure 2.

Procedures where GA is used routinely include the ablation of scar-VT substrate, lead extraction, or if the patient expresses a very strong preference upfront. Unless pre-scheduled, there is no facility for the conversion from CS to GA on the day of the procedure. If heparin is used intraprocedurally, it is routinely reversed with up to 100 mg of intravenous protamine prior to sheath removal.

The operator reviews all their patients post procedure, and importantly, also confirms their suitability for nurse-led discharge. Based upon the course of their procedure, every patient is prescribed a pre-specified minimum period of observation to be undertaken prior to discharge. For EP, this is 4 hours if patients have been fully heparinized, or 2 hours otherwise. For CIEDs, chest radiography is arranged for all new lead implants at 2 hours to maximize the time window for any wound, lead, or lung issues to manifest. Crucially, this is aligned with a tight adherence to theater scheduling so that typically all procedures are completed by 17:00, and there is a late closing time of 20:00 for our day-procedure unit. In the rare event of a day-case patient needing to stay beyond this time, our institution operates a policy of “anytime discharge” such that if patients require longer observation but are still likely to meet the criteria for SDD (Table 1), they can be transferred to an inpatient ward and their discharge facilitated from there.

All patients receive an information leaflet containing the telephone contact information for our arrhythmia specialist nurse team, in case of post-discharge concerns. Day-case patients receive a telephone call by the nursing team following discharge in order to confirm post-procedural well-being as well as to pick up any delayed complications.

In May 2020, the NHS published an Operating Framework to facilitate the maintenance of service capacity while minimizing the nosocomial transmission of COVID-19.⁴ The core tenets of this framework emphasized the careful planning, scheduling and organization of clinical activity, and encouraged excellence in infection prevention and control (IPC), including the testing of staff and patients. These principles were incorporated early into our service delivery model.

All CIED and EP procedures were categorized and prioritized as acute and urgent, semi-elective, or non-urgent (Table 2). Patients unlikely to meet criteria for SDD were identified at pre-assessment. All elective patients were advised to isolate for 2 weeks prior to admission. Where feasible, this was supplemented with a COVID-19 test conducted a maximum of 72 hours prior to admission. Patients in remote areas sometimes did not receive testing kits in a timely fashion. Those patients without testing confirmation were isolated upon arrival to hospital and deferred until a test result was available. This inevitably resulted in some last-minute procedure cancellations.

For elective cases, the use of GA was reduced significantly as anesthetists were diverted to provide COVID-related services. Where GA was utilized, up to 20 minutes of additional time before and after every procedure was mandated for adequate air exchange between patients. Full personal protective equipment (PPE) was utilized during periods of potential aerosol generation such as intubation and extubation.

Patients attending for unplanned urgent or emergency care were tested for COVID-19 upon admission, and appropriate infection control measures were implemented as needed. For those who initially tested negative, the test was repeated 5-7 days after admission.

Managing staff sickness, or those vulnerable to infection or its consequences, has been a challenge. To offset this, IPC procedures have been rigorously implemented throughout our institution. All symptomatic staff or members of their household were offered testing for COVID-19. Routine and strategic testing of asymptomatic frontline staff was also deployed.

Staff members were encouraged to undertake individual risk assessments, so that where necessary there could be adjustments made in scope of working, eg, avoiding contact with acute patients who had an unknown (possibly positive) COVID status. The use of appropriate levels of PPE adhering to national guidance from Public Health England has been encouraged among staff. Healthcare worker transmission potential has been minimized by reducing movement between different areas, social distancing, and good hand and respiratory hygiene. Education activity and multidisciplinary team meetings have been undertaken virtually throughout this period.

Figure 3 summarizes the impact of changes on our procedural volume as a result of COVID-19. Activity was reduced overall by 21% for CIED implantations and 30% for EP, with much of this being incurred at the onset of the pandemic. For September to December 2020, we achieved a SDD rate in EP of 60%, including 42% for AF ablations.

In the context of the COVID-19 pandemic, SDD has been critical in maintaining EP and CIED activity.
Fundamental to this has been our dedicated day-case unit, and an institution aligned with SDD across the patient journey. These convergent structures have created robust systemic resilience during what has been the greatest test of organized healthcare provision in modern history.

Disclosure: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Rao reports consulting fees and support from Medtronic for attending meetings and/or travel, and fees received from Boston Scientific and Medtronic for delivery of educational activity. Dr. Gupta reports institutional research grants from Biosense Webster, Boston Scientific, and Medtronic, consulting fees from Boston Scientific for an advisory board meeting, and webinar fees from Boston Scientific.