Who We Are
Vancouver General Hospital and St. Paul’s Hospital are the 2 tertiary academic hospitals in Vancouver that provide heart rhythm care for a large patient population across the province of British Columbia, Canada. Both centers are affiliated with the University of British Columbia (UBC) with a coordinated electrophysiology (EP) training program between the 2 sites. The combined heart rhythm program performs over 1100 ablation procedures and 1500 device implant procedures per year. Almost half of the 1100 ablation procedures are for atrial fibrillation (AF), and are performed by 6 operators using a mix of radiofrequency and cryoballoon ablation. Dr. Deyell serves as the EP lab director for St. Paul’s Hospital and Dr. Andrade serves as the EP lab director for Vancouver General Hospital.
Our Journey to Same-Day Discharge for Catheter Ablation
The rapid growth of ablation for atrial fibrillation in the early 2000s1,2 resulted in pressure on limited inpatient beds at our institutions. As referrals for atrial fibrillation ablation grew, our program had to meet the challenge of providing this important therapy while minimizing the impact on inpatient resources. As both St. Paul’s Hospital and Vancouver General Hospital had established programs for same-day discharge after percutaneous coronary intervention, device implantation (pacemaker and defibrillator), and non-complex ablation (eg, supraventricular tachycardia, or typical flutter), it made sense to explore the possibility of same-day discharge after complex catheter ablation. While the complexities of atrial fibrillation ablation, including general anesthesia and anticoagulation, provided initial challenges to achieving same-day discharge, a program of routine same-day discharge was initiated in the early 2000s under the guidance of Dr. John Yeung-Lai-Wah. Concurrently, colleagues at Royal Jubilee Hospital in Victoria initiated a similar program, leading to same-day discharge after atrial fibrillation ablation becoming the standard of care across our province of 5 million people.
While the origins of same-day discharge were driven by necessity, the protocol has been refined over the years to meet the evolving landscape of atrial fibrillation ablation. Nursing leadership has been instrumental in ensuring comprehensive and standardized care for all atrial fibrillation ablation patients. Jacqueline Forman, Clinical Nurse Specialist, has led a dedicated team of allied health professionals who ensure that same-day discharge does not compromise patient care and recovery.
How We Achieve Same-Day Discharge for Most Patients
All patients undergoing catheter ablation for atrial fibrillation receive their peri-procedural care through the local multidisciplinary AF clinic. These clinics provide pre-procedure education and teaching, and act as a resource for patients before and after the ablation procedure. The pharmacists at these clinics manage peri-procedural anticoagulation and antiarrhythmic agents, with the nurses and nurse practitioners acting as points-of-contact across the patient journey.
One of the key reasons for the success of the same-day discharge program has to do with support, education, and managing expectations. At the time of consultation, patients are educated about the logistics of their ablation procedure, which includes a conversation regarding the need for home supports to manage following same-day discharge. Patients are aware that we plan for admission only in cases of severe comorbidities or in cases of inadequate social support for safe discharge home, and that almost all patients can expect to be discharged on the same day of the procedure.
Day of the Procedure
Our Cardiac Short Stay Units operate from 7am to 8pm daily. We prioritize complex ablations as cases to be done earlier in the day, but same-day discharge is the default protocol regardless of the finish time for the case. Patients are admitted to the cardiac short-stay unit approximately 3 hours prior to their procedure. For most patients, their direct oral anticoagulants (DOACs) are held 24 hours prior to the procedure (last dose 24 hours prior); however, warfarin is continued uninterrupted with a target INR of 2.0-3.0 for the day of the procedure.
The vast majority of our AF ablation procedures are done under general anesthesia, regardless of the ablation technology. Two to four femoral venous punctures are performed per patient, with the use of ultrasound guidance left to the discretion of the operator. Intravenous heparin is given during the procedure, targeting an activated clotting time (ACT) of ≥300 seconds.
At the end of the procedure, IV protamine is given prior to sheath removal. The venous sheaths are removed in the EP lab (regardless of ACT), and manual compression is maintained in the lab for a minimum of 10 minutes following extubation. Hemostasis is achieved in the lab for the majority of patients. Additional manual hemostasis or clamping is performed at the discretion of nurses in the recovery area. We have not routinely employed sutures or hemostatic devices for AF ablation at our centers.
Patients are maintained on bedrest for 3 hours in the recovery area, where they are monitored by nursing. If there are no bleeding or other post-anesthesia concerns, patients are ambulated under supervision of the nurses after the period of bedrest. If ambulation is uneventful, the nurses provide education to the patient and the support person taking them home. Standardized post-procedure discharge instructions are reviewed by the nurses and written instructions are provided to the patient (Figure 1). The discharge education materials address what the patient can expect during recovery and what should prompt them to seek medical advice. The patient is then discharged to the care of their support person. For the large proportion of our patients who are from out of town, we encourage them to stay nearby for the first night following the procedure before travelling home.
DOAC anticoagulation is typically resumed 6 hours post sheath removal if there are no bleeding concerns. Antiarrhythmics are typically continued for the first 3 months post ablation.
If there are concerns from the physicians or nurses regarding suitability for discharge, then the patient is admitted to the cardiology ward for ongoing observation in a monitored setting.
All AF ablation patients are followed by the Atrial Fibrillation Clinics, and therefore, have access to the AF clinic pharmacist and nurse via telephone. The AF Clinic pharmacist or nurse performs a routine call at 10 days post ablation to review their progress and to identify concerns or complications. Patients are seen by the physician and nurse practitioner at 3, 6, and 12 months post ablation.
How Can We Improve?
We have recently reported the safety and efficacy of same-day discharge from Vancouver and Victoria, British Columbia.3 In this series of more than 3000 consecutive patients, the rate of readmission at 48 hours was 1.9% in those discharged same day, which was comparable to those with planned overnight admission (2.9%, P=.124) and significantly less than those admitted with acute complication (5.2%; P=.039). Similarly, the rates of 30-day readmission and complications at 30 days did not differ between those discharged same day and those with planned overnight admission, with both groups having lower event rates compared to those admitted with acute complication. With enhancements to our same-day discharge protocol, we have now achieved over 90% same-day discharge, which is substantially higher than the 79% (2418 of 3054) achieved in the aforementioned cohort from 2010-2014.
Depending on the jurisdiction, it is estimated that same-day discharge would save the healthcare system an estimated $2,661 per procedure. In relative terms, given that overnight admission is estimated to comprise approximately 15% of the procedural costs, it suggests that one extra procedure could be funded for every 6-7 patients discharged the same day.
Nonetheless, there is always room for improvement. Access site bleeding remains one of the most common barriers to same-day discharge, and we will be evaluating the use of additional hemostatic measures, such as sutures, to facilitate discharge. The rate of readmission to hospital and to the ER remains higher than desired, and we are exploring interventions to further reduce healthcare utilization after discharge.
While our same-day discharge program grew out of necessity, we hope that the lessons we have learned can help other centers around the world implement similar protocols. As the volume of AF ablation increases and the procedure becomes shorter and more refined, same-day discharge can help minimize the cost and resource utilization of AF ablation.
Disclosures: Dr. Deyell and Ms. Forman have no conflicts of interest to report regarding the content herein; Dr. Andrade reports a grant from Medtronic. Dr. Andrade also reports grants from Baylis and personal fees from Biosense Webster outside the submitted work. Dr. Deyell reports grants and personal fees from Biosense Webster, and personal fees from Abbott, Medtronic, Servier, Bayer, and BMS-Pfizer outside the submitted work.
- Kumar S, Walters TE, Halloran K, et al. Ten-year trends in the use of catheter ablation for treatment of atrial fibrillation vs. the use of coronary intervention for the treatment of ischaemic heart disease in Australia. EP Europace. 2013;15:1702-1709.
- Chow JY, McClure G, Belley-Côté EP, McIntyre WF, Singal RK, Whitlock RP. Costs of surgical ablation of atrial fibrillation in Ontario, Canada from 2006 to 2017. J Card Surg. 2020;35:3451-3454.
- Deyell MW, Leather RA, Macle L, et al. Efficacy and safety of same-day discharge for atrial fibrillation ablation. JACC Clin Electrophysiol. 2020;6:609-619.