The slippery slope of shorter hospital stays

This story has become all too familiar. The patient enters the ER with crushing chest pain and their EKG shows an acute MI, (known today in the colloquial as STEMI, for ST-elevation myocardial infarction). The interventional cardiologist is summoned quickly and in less than 90 minutes from the patient’s arrival across the ER door threshold, he or she is on a cardiac cath lab table, where a coronary stent is quickly placed to unblock the artery causing the pain and infarct. Relief is instantaneous and the patient is quite grateful. They are told they must take aspirin and clopidgrel for one year, quit smoking, and make lifestyle changes.

The good thing about the modern treatment of a STEMI with a coronary stent is that it is quick, easy to do (in the right operator’s hands), it saves lives, and pain is immediately gone. The only bad thing about the procedure is the fact that the pain is gone. Before you can say “holy clopidigrel,” the patient soon forgets that anything has happened to him and is ready to go home.

How far we have progressed in cardiology can only be appreciated sometime by looking in the rearview mirror. Before the age of angioplasty and stents, and before thrombolytic therapy, there was no way to directly intervene and treat the acute infarction. We had to treat the aftermath with all of its associated complications (like heart block, cardiogenic shock, or heart failure). It was not unusual for the average length of stay to be 2 to 4 weeks with substantial morbidity and mortality. However, at least the patient did know that they had a heart attack.

Since patients feel well it as if “nothing serious” has even happened, they and hospitalists expect discharge in less than 24 hours.  Leaving alone for the moment whether a less than 24-hour stay is safe, there is another consideration. There is scant time to educate the patient on proper diet, smoking cessation, life style changes, cardiac rehabilitation, medications, return to work, and expectations for the future. With the endless push for trimming hospital lengths of stay for everything, some institutions are experimenting with same day discharges for elective coronary interventions.

If this becomes the standard of care, then why not same day post STEMI discharges as well? The advent and ease of the radial artery approach (as opposed to the standard femoral artery) has made this prospect even more enticing.

Here is a cautionary tale. Mr. Jones comes into our local ER last week with a STEMI of the inferior wall. He is immediately stented. Just after he arrives in the intensive care unit, he has a brief tachycardia, not caught on telemetry, but seen by the nurses. He starts to loose consciousness and has very short and successful CPR. He feels fine. The following afternoon, when discharge was anticipated, he develops severe chest pain and is taken back to cath lab. It is now noted that the repaired right coronary artery from the previous day, is totally occluded. Three new stents are placed and the following day he is discharged home in stable condition. Now what if he had been discharged home the morning after his STEMI and had another MI and or died at home? I would not want to have to defend that chain of events in court.

For me, this nonstop push for ever shorter hospital stays is a slippery slope. At some point, we as physicians have to stop acquiescing to the demands of hospitalists and institutional bean counters. A return to common sense is needed. For me, or a family member, a one-day discharge after a STEMI will never be acceptable.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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  • civisisus

    Presumably Dr Motokoff is going to spend every moment of his patient’s extra time in the hospital at the patient’s bedside-or to assign a clinical colleague to do the very same thing.

    Otherwise, why not send the patient home appropriately monitored, and have a well-trained, possibly non-physician clinician visit the patient in his/her home to work with them in their own homes to modify behaviors as needed to accommodate their new health status, in the place where they’ll actually have to practice those changes, rather than in a germ-filled, unfamiliar hospital?

    Because it’s not really clear what the clinical advantage is to the person remaining in that hospital bed on the off-chance Dr M’s anticipated negative consequences, with their dwindling probability of occurrence, come about.

    • rtpinfla

      The clinical advantage of remaining in the hospital on the off chance of a negative consequence isn’t quite the right question. The more appropriate question is, what is the probable outcome of a potential complication (negative consequence)? If it’s death, the advantage would be that the patient is much less likely to die. And clearly, that’s a preferable outcome and probably worth hanging around for and extra 18-24 hours.
      Of course, some suit is going to calculate the cost benefit of quicker discharges. If the equation favors letting a few people die to achieve a better bottom line at the end of the year (even with a few out of court settlements factored in), you bet they will be kicking your butt out of that bed as soon as you can stand up.

      • DeceasedMD1

        the funny thing is even if you were wealthy and paid cash for the extra day, they would still kick you out early.

    • guest

      Um…by appropriately monitored, do you mean on telemetry in order to monitor for the arrhythmias that are a common sequelae of MI? And if the patient were at home, and developed a potentially lethal arrhythmia, what exactly do you think could be done about it in the patient’s home, unless there were trained personnel available at his home around the clock?

  • 1SB

    My father-in-law had one of those chest pain events that they wanted to discharge him home after, “monitored” by his 75 year old wife with Alzheimer’s disease.

    I told them, it they sent him home and he had another episode of chest like the one he was in the ER for, he would never make it back. His wife would not be able to do anything to help him. He was the one who called the ambulance that brought him to the hospital.

    The ER nurse noted that his enzymes appeared a little off and offered to call Cardiology to come see him. Luckily they admitted him for overnite observation.

    He has a severe bout of chest pain that nite and they sent him to be cardiac cathed the next morning. A stint was placed. He would not have made it had he not stayed at the hospital.

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