Same day discharge (SDD) following percutaneous coronary intervention (PCI) is a safe way to optimise hospital resource use through reducing length of stay and decreasing healthcare costs. However, the uptake of SDD is variable worldwide and strategies that support its implementation are lacking. This study was undertaken in an Australian tertiary hospital; its primary aim was to evaluate how SDD was implemented (a process evaluation), and its secondary aim was to determine the effects of implementation on patient and healthcare delivery (an outcome evaluation).
This study was informed by an effectiveness-implementation hybrid type III design and was guided by the Iowa Model of evidence-based practice. In the process evaluation (the primary component of the hybrid type III design), a convergent parallel mixed methods design was applied. Multiple data collection methods included observations, surveys, and interviews. Healthcare professionals (n=50) were observed in practice and field notes were taken. Quantitative data, including patient selection and healthcare professional guideline adherence, were collected through observations of clinical practice. Patients (n=39) and family (n=31) satisfaction was measured using surveys, and experiences of SDD were evaluated through patient (n=31) and family (n=23) phone interviews. Healthcare professional (n=26) semi-structured interviews were conducted to explore factors that influenced implementation (qualitative data).
Descriptive statistics were used to analyse quantitative data about patient selection, healthcare professional guideline adherence, and patient and family surveys. Qualitative data from patient and family interviews, and from field notes and healthcare professional interviews, were analysed using inductive and deductive content analyses respectively; the latter was guided by the theoretical domains framework.
An uncontrolled before-after study design was adopted in the outcome evaluation (the secondary component of the hybrid type III design). This allowed comparison of two groups of outpatients who underwent PCI 6 months in the baseline and 6 months in the post-implementation periods. Data were extracted from the hospital-based data repositories and collected from electronic medical record when extraction was unavailable. Descriptive and inferential statistical analyses were undertaken.
During the 6-month implementation, 308 patients underwent PCI; 22 were discharged home the same day, three of whom were inpatients. To provide context for the process evaluation, the outcome evaluation findings are reported first; no statistically significant differences were identified between the baseline (n=66) and post-implementation (n=82) groups in post-procedure complications and readmissions. Due to a small number of outpatients being sent home the same day (n=19), the effect of SDD on reduced healthcare costs or decreased length of stay was minimal.
The process evaluation findings demonstrated that the SDD patient selection criteria were more conservative than those reported in literature. Patients were often excluded from SDD due to being an inpatient, having a low estimated glomerular filtration rate, and femoral access; they could have been eligible for SDD if criteria from the literature were applied.
The overall guideline adherence rate for post-procedure care was 77.3%. The highest adherence rates were for tasks that were already routine practice: electrocardiogram performed, follow-up appointments with a cardiologist made, and patient seen by a cardiac rehabilitation nurse and a pharmacist before discharge. Poorer compliance was observed for tasks introduced for SDD, which included discharge preparation and next-day phone follow-up.
Analysis of the surveys and interviews with patients and families found that their involvement in the SDD process was suboptimal. However, most were satisfied with the process and described positive experiences.
Analysis of field notes and healthcare professional interviews revealed five domains closely linked to factors that influenced SDD implementation: beliefs about consequences, professional role and identity, resources, behaviour regulation, and optimism. Healthcare professionals considered SDD to have some benefits but also expressed concerns about its safety. They reported varying levels of involvement in the change process and felt roles and responsibilities were ambiguous. Inadequate resources and suboptimal communication also hampered implementation. Enablers included having a daily nursing huddle, healthcare professionals holding a positive attitude towards SDD, and maintaining optimism about the achievement.
Conclusion and recommendations
This was the first study to examine SDD implementation; it highlights opportunities to improve the guideline elements and also the implementation process. Recommendations for future practice centre on development of strategies to improve patient selection criteria and promote the involvement of patients and families in care.||