Same-day discharge, flu vaccine laws

Research summaries from ACP Hospitalist Weekly.

Decision pathway provides checklist of factors to consider before same-day discharge after nonurgent PCI

A decision pathway from the American College of Cardiology aims to help clinicians make decisions around same-day discharge after percutaneous coronary intervention (PCI).

The expert consensus decision pathway, published online on Jan. 7 by the Journal of the American College of Cardiology and in the Feb. 16 issue, provides clinicians with a checklist of clinical, social, and facility/systems factors that indicate whether a patient can be safely considered for same-day discharge. It is applicable to patients presenting for an elective PCI but is not applicable to patients presenting with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction.

The checklist for consideration of same-day discharge after PCI includes the following:

  • Pre-PCI considerations include the physician's input about whether the patient is a candidate for same-day discharge, as well as three social factors: whether the patient or caregiver can call 911, whether a caregiver is available if needed, and whether the patient is willing to go home. In addition, a staff/systems factor to consider is having the scheduler inform the patient about the possibility of same-day discharge and schedule the PCI early enough in the day to allow for reasonable observation before same-day discharge.
  • Post-PCI considerations include whether the patient is willing to go home, as well as the following clinical factors: perioperative complications, success of PCI, exacerbation of disease, and change in mental status from baseline.
  • A predischarge checklist includes the following: administration of P2Y12 inhibitor loading dose, patient receipt of prescription for P2Y12 inhibitor for at least 30 days, prescription for aspirin and statin, referral to cardiac rehab, follow-up call with the patient on the day after discharge, and follow-up appointment. In addition, the catheterization laboratory/postprocedural staff should provide education to the patient on monitoring the access site and the emergency number to call, the pathway said.

“PCI has evolved in safety and efficacy such that many patients can leave facilities the same day as the procedure, with retrospective data showing no increase in death or rehospitalization compared with patients who stay for overnight monitoring.... Implementing this checklist, and thus likely widening the pool of patients who can be identified as candidates for safe [same-day discharge], will lead to greater patient satisfaction and awareness as well as increased savings within facilities,” the authors of the pathway wrote.

Laws promoting flu vaccination in hospital workers associated with improved mortality rates

State laws promoting flu vaccination among hospital workers may help decrease mortality for flu and pneumonia in the community, a recent study found.

Researchers performed a quasiexperimental observational study to evaluate the effect of state-level laws regarding flu vaccination in hospital workers on pneumonia and influenza mortality. Data on pneumonia and influenza mortality per 100,000 persons by state and by month, population-wide and by age group, were obtained from the National Vital Statistics System for 1995 to 2017. During this time period, 13 states and the District of Columbia passed laws on flu vaccine in hospital workers, most requiring hospitals to provide vaccination onsite for employees and some mandating vaccination or face masks for unvaccinated workers. Six of the 14 laws also included health care workers outside the hospital setting. Changes in mortality rates for states that adopted these laws and those that did not were compared using linear and log-linear models. The study results were published Jan. 5 by Annals of Internal Medicine.

Image by Getty Images
Image by Getty Images

The study's main analyses looked at 17 influenza years from 1995-1996 through 2016-2017 in which the vaccine was well matched to the circulating virus strains (five influenza years with match rates below 50% were excluded). The proportion of U.S. hospital workers who were subject to a flu vaccine law ranged from below 2% in 1995 to approximately 38% in 2017. Rates of hospital worker influenza vaccination rates doubled from 43% in 1997-1998 to 87% in 2016-2017. In the years when the flu vaccine was well matched to the circulating strains of the virus, implementation of state laws requiring hospitals to offer vaccination to their employees was associated with a 2.5% reduction in monthly mortality rates for pneumonia and influenza (−0.16 death per 100,000 persons [95% CI, −0.29 to −0.02]; P=0.022). The largest effects were seen for elderly people and during peak influenza months.

Among other limitations, the researchers noted that they did not have information on hospitals' independent vaccination requirements and that their study used large-scale national data and they could therefore not evaluate the effect of vaccination on more specific outcomes. They concluded that state laws promoting flu vaccination for hospital workers may help prevent deaths related to influenza and pneumonia, particularly among those who are elderly. “Overall, our findings are consistent with the idea that vaccinating hospital workers reduces the spread of influenza and, by doing so, protects the lives of more vulnerable populations,” they wrote.