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What are the clinical and financial benefits of using same-day discharge with
patients undergoing catheter ablation for atrial fibrillation? A retrospective study
comparing same-day discharges versus observation/inpatient patients.
By
Matthew Hodas, CRNP, NP-C, FNP-BC
Pennsylvania Western University
250 University Avenue
California, PA 15419
A DNP Research Project Submitted to Pennsylvania Western University
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
April 2023

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Dean, College of Health Sciences

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Abstract
Atrial fibrillation is the most common dysrhythmia and has significantly impacted
healthcare staff and systems. Catheter ablations remain the most effective tool in the treatment of
atrial fibrillation, and yet these have often contributed to hospital admissions and costs. Sameday discharges are a safe and cost-saving method being used more in this patient population.
This study was completed to evaluate and compare same-day discharge versus admission
following catheter ablation.
In the study, there were 321 patients who underwent catheter ablation for atrial
fibrillation over 12 months from July 2021 to July 2022. Of these 321 patients, there were 74
same-day discharges. 30-day readmission rates for both samples were similar, with 4 (4%)
patients readmitted following same-day release and 3 (2%) patients readmitted following
observation or inpatient admission. 90-day readmission rates for both samples were also similar
at 2.7% for same-day discharges and 1.2% for observation/inpatient admissions. There was a
cost savings of at least $37,000 using same-day discharge versus at least $123,000 in costs for
admission for observation or inpatient. Based on this study, the use of same-day discharge in
catheter ablation for atrial fibrillation is reaffirmed as safe and cost-effective and should be
considered in routine practice.

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Chapter 1: Introduction
Introduction
Health care is constantly changing, and the recent pandemic exposed many issues and
accelerated some changes. Providers, nursing, and staff shortages have become more problematic
in many healthcare systems. Healthcare costs are constantly being scrutinized so that they may
be less burdensome for systems, insurance companies, and patients. One practical intervention
implemented to reduce costs for many procedures and surgeries has been the increasing use of
same-day discharges (Kowalski et al., 2020). Using same-day discharges with patients at low
risk for readmission or post-procedure issues is a method to decrease hospital and patient costs
and ease the burden on hospital staff. Depending on the procedure and location, costs have been
documented and forecasted to save tens of thousands per facility annually. Cumulatively
nationwide and internationally, same-day discharge can save millions of dollars for patients and
healthcare systems (Reddy et al., 2020).
For this program evaluation, I have looked at some of the clinical and financial impacts
of same-day discharges in patients undergoing atrial fibrillation ablations. This evaluation is of a
program instituted at a 480-bed regional hospital in northwest Pennsylvania. In this hospital
system, many circumstances can create challenges with patient safety. Like most systems,
staffing and bed availability issues are at the forefront of challenges to care. An American
Nursing Foundation (2022) survey of over 12,000 nurses found that more than half of them plan
on leaving or are considering leaving their current positions within six months. Over 89% of the
respondents in this survey reported staffing shortages at their institution. The lack of staff created
delays or cancellations of elective procedures.

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Background
Atrial fibrillation is the most common cardiac arrhythmia. An estimated 3-6 million
people in the United States live with atrial fibrillation, which is expected to grow to over 12
million in less than ten years (Vaillancourt et al., 2022). Atrial fibrillation increases one's risk for
stroke, which is related to 15-20% of thromboembolic strokes. The lifetime risk for developing
atrial fibrillation after age 40 is nearly 25%. Patients with atrial fibrillation also have a higher
risk for hospitalization, with 1 in 3 requiring hospitalizations within a year of diagnosis of atrial
fibrillation (Vaillancourt et al., 2022).
Patients with atrial fibrillation have multiple options for treatment, including
antiarrhythmic therapy, cardioversion, and catheter ablation. Catheter ablation has been shown to
have a higher success rate in treating atrial fibrillation. Studies have shown a 64% reduction in
atrial fibrillation-related hospitalizations after catheter ablation, a 52% reduction in
cardioversions, and a 65% shortened length-of-stay (Vaillancourt et al., 2022). In addition to
catheter ablation becoming the standard treatment for atrial fibrillation, it has decreased hospital
and patient costs. With further use of catheter ablation as first-line therapy, same-day discharges
with these patients are also becoming more standard.
Same-day discharges are not new but becoming more widespread after the COVID-19
pandemic forced significant changes to care. Same-day discharges are safe for many procedures
that once led to more extended stays. They are a proven cost-saving practice for hospitals and
outpatient surgeries. Studies continually show that there is significant cost reduction related to
same-day discharges. The Centers for Medicare and Medicaid Services reported a reimbursement
rate for electrophysiology studies and atrial fibrillation ablations of nearly $21,500 (Vaillancourt
et al., 2022). At the facility of this study, it was reported by the Director of Finance that the

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average cost saved by same-day discharge is about $500 per patient. Kowalski et al. (2020)
reported that hospital savings ranged from $45,000 to $84,000 annually across U.S. hospitals
with same-day discharge use following atrial fibrillation catheter ablation. Reddy et al. (2020)
reported that hospital savings using same-day discharge totaled over $81,000 over 13 months at
the Royal Papworth Hospital in the United Kingdom. This was attributed to 128 same-day
discharges.
PICO question
What are the clinical and financial benefits of using same-day discharge with patients
undergoing catheter ablation for atrial fibrillation? A retrospective study comparing same-day
discharges versus observation/inpatient patients.
Theoretical Framework
In this project, Lewin's Change Theory is the fundamental framework. In summary, the
Change Theory has three stages and involves the process of unfreezing, changing, and
refreezing. Unfreezing involves establishing a new method or practice by letting go of an old
one. The second stage, changing, involves the adaptation of a new practice that is more
productive and useful. The third stage is refreezing, establishing the new practice as the standard
operating procedure or the new norm.
Specific to this project, the old practice that is to be let go is the observation and
hospitalization of every patient after a procedure which in this case is an atrial fibrillation
catheter ablation. This is the unfreezing stage. The changing stage is enacting and promoting
same-day discharge for these ablation patients. Finally, the refreezing stage involves the
acceptance of same-day discharge for atrial fibrillation ablation patients as standard and becomes
the expectation for these patients regularly.

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Problem Statement
Healthcare costs are consistently higher than desired for patients and healthcare systems.
Costs and ways to decrease them are always a national and local focus. The COVID-19
pandemic created strain and opportunity for patients and healthcare systems. The ongoing strain
on staff and patients has caused elevated risks and healthcare delays in many areas. Patients
needing elective treatment are often deferred due to patients of higher acuity and need. With that
said, same-day discharging is a way to allow appropriate care for those in urgent need but not
delay care for other patients. Implementation and detailed evaluation of this process are
necessary to promote long-term use.
Purpose
This project aimed to look at the safety and cost-effectiveness of same-day discharge of
patients following catheter ablation for atrial fibrillation at a western Pennsylvania hospital that
is amongst the busiest in this area in their health care system. As discussed above, there has been
ample research on the use and safety of same-day discharges for patients undergoing various
procedures. The use of same-day discharges has been studied for over ten years worldwide. With
the impact of the COVID-19 pandemic and prior understanding of same-day discharge safety,
there was an opportunity for more widespread use. After elective procedures were resumed, the
hospital implemented its same-day discharge policy in 2020. With continued use, there may be a
significant financial impact in the form of cost reduction. It is also expected that adverse patient
outcomes will be similar or improved with same-day discharge. Ultimately, same-day discharge
should be the expectation for first-case catheter ablation.
Research Question

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In this quantitative research, using same-day discharge with atrial fibrillation ablation
patients is being studied in several aspects. The research looks at patient clinical outcomes and
financial impact. The following research question has guided this study.
RQ1: What are the clinical and financial benefits of using same-day discharge with
patients undergoing catheter ablation for atrial fibrillation?
Hypothesis
Based on the existing literature and the process involved in this project, it was
hypothesized that same-day discharges are both safe and cost-saving for patients undergoing
atrial fibrillation catheter ablation. It is believed that complication and readmission rates for these
patients will be nearly the same or better than those who stay overnight for observation. There
will likely be a significantly positive financial impact with these same-day discharges.
H10: There will be no difference in clinical outcomes or financial impact between
patients discharged on the same day and those admitted for observation or as inpatients.
H1a: There will be a significant or statistical difference in clinical outcomes when
comparing patients discharged the same day versus those admitted for observation or as
inpatients.
H1b: There will be a significant or statistical difference related to cost when comparing
patients discharged the same day versus those admitted for observation or as inpatients.
H1c: There will be a significant or statistical difference in clinical outcomes and cost
when comparing patients discharged on the same day versus those admitted for
observation or as inpatients.
Rationale and Specific Aims

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Prior research regarding same-day discharge use in health has primarily been done
retrospectively. They are done as observational cohort studies looking at historical patient data.
The advantages of retrospective cohort studies include the ability to study multiple outcomes
associated with a single exposure, the ability to choose a subject-specific exposure, and the
ability to obtain a larger sample with broader inclusion criteria and fewer exclusion criteria.
Research obtained using cohort studies can be more generalizable in clinical practice (Wang &
Kattan, 2020).
The use of cohort study in this research allows the population of atrial fibrillation patients
to be evaluated regarding more than one factor. This quantitative study was performed with this
in mind. The evaluation looked at the impact of same-day discharge on atrial fibrillation ablation
patients and various factors affiliated with them.
Significance
The significance of this study is related to the impact on both local and worldwide
practice. Prior research has repeatedly determined that using same-day discharges in catheter
ablation patients is safe and cost-effective. The significance of this particular study is in two
parts. It further reinforces the consistency of prior research findings worldwide in other systems.
It also determines the practicality of the same-day discharge process in a local health system and
project. This research can change historical processes that may be unnecessary in current and
future patient care. It may result in financial benefits and savings for patients and healthcare
systems.
Nature of the Study
As mentioned, this research study was completed as a retrospective cohort study. This
type of design is best when evaluating the process of same-day discharge because multiple

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outcomes can be evaluated from a specific population. Bias is limited as the sample population is
already determined. No significant patient input should impact this study's quality and specific
measures.
Definition of Terms
Numerous definitions should be discussed as part of this project. Atrial fibrillation,
catheter ablation, cryoablation, radiofrequency ablation, anticoagulation, major complications,
minor complications, and same-day discharge are terms to be understood.
1. Atrial Fibrillation (AF)-A type of arrhythmia that occurs when the heart beats irregularly
and often too fast. It is a common type of arrhythmia that affects millions of people
worldwide.
2. Arrhythmia- An irregular heartbeat that can occur when the electrical signals that control
the heartbeat are disrupted
3. Catheter Ablation- A medical procedure used to treat certain arrhythmias, including atrial
fibrillation. It involves the insertion of a catheter into a blood vessel and using it to
destroy a small area of the heart tissues causing arrhythmia.
4. Radiofrequency Ablation- A type of catheter ablation that uses high-frequency radio
waves to destroy heart tissue causing arrhythmias.
5. Cryoablation- A type of catheter ablation that uses extreme cold to destroy heart tissue
causing an arrhythmia.
6. Same-Day Discharge- A procedure in which patients who undergo catheter ablation for
atrial fibrillation can go home the same day as the procedure.
7. Anticoagulation Medication – Drugs used to treat blood clots and stroke in patients with
atrial fibrillation

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8. Major Complications- serious and potentially life-threatening side effects can occur after
a medical procedure, such as catheter ablation.
9. Minor complications- Less serious side effects that can occur after a medical procedure,
such as catheter ablation, but typically do not pose a threat to the person’s health or life.

In this project, major complications are defined as adverse outcomes that result in
permanent damage or even death. Major complications affiliated with atrial fibrillation ablations
include in-hospital death, stroke, access site complication requiring intervention, cardiac
tamponade requiring drainage, phrenic nerve injury, cardiac arrest, advanced heart block, and
atrio-esophageal fistula. Minor complications affiliated with atrial fibrillation ablations include
pericarditis or groin access site hematoma (Steinbeck et al., 2018).
Assumptions, Limitations, Delimitations
As this study was a retrospective cohort study, there were no significant assumptions
based on the specificity of the procedure and the outcomes being evaluated. A limitation of this
study is that there needed to be funding for this research. The lack of funding may impact
motivation, time, and investigator participation in research. Delimitations of this study include
location and data timeframe. This study was performed at one specific healthcare center in
northwest Pennsylvania. This facility is one of many in the entire system. Another delimitation is
the data timeframe. The process being studied was evaluated over 12 months. Ongoing research
can include data from the inception of the process and data from dates past the chosen
timeframe.
Chapter 2: Literature Review

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Same-day discharge after the completion of catheter ablation for arrhythmia is a recent
development in treating heart rhythm disorders. This approach can allow patients to return home
the same day as their procedure rather than requiring them to stay overnight in the hospital.
Some students have evaluated the safety and effectiveness of same-day discharge after catheter
ablation. The students generally found that same-day discharge is appropriate and safe for
selected patients and can result in improved patient satisfaction and decreased healthcare costs.
However, it is essential to note that same-day discharge may only be prudent for some
patients. Careful selection of patients and close monitoring of their recovery is essential to ensure
the best possible outcomes. Additionally, further research is needed to understand the long-term
effects of same-day discharge and to determine the best methods for achieving it. Studies looking
at both cost savings of same-day discharge and the safety of same-day discharges have been
completed. Chu et al. (2021) performed a retrospective review of possible same-day discharge
patients who underwent catheter ablation in 2019. In their study, there were 157 eligible patients
for same-day discharge, 63% of first-case ablations. The estimated financial impact of a
population of this size was between $1.11 and $1.48 million dollars (Chu et al., 2021).
Amin et al. (2018) pointed out in a study involving percutaneous coronary intervention
(PCI) that there are potential cost savings of at least $5000 per case using same-day discharge. In
this study, over 600,000 PCI patients were evaluated from January 2006 to December 2015. It
was found that few of these patients were discharged the same day as an intervention, but many
could have been candidates for it. The estimated total savings for hospitals with same-day
discharges for PCI was nearly $577 million (Amin et al., 2018). Creta et al. (2020) studied sameday discharges in patients undergoing atrial fibrillation ablations. Their study took place in
London, UK, and identified 727 subjects who met the criteria for same-day discharge. Their

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study conducted in 2017 found that same-day discharges are safe and effective, citing that there
was only a 3.7% complication or 30-day readmission rate (Creta et al., 2020).
He et al. (2021) performed a multicenter cohort study of the safety and cost-effectiveness
of same-day day discharge for left atrial ablation. In their study, 967 patients from January 2011
to December 2020 underwent left atrial ablation. Of these patients, 414 were deemed candidates
to be discharged the same day. Five of these patients had significant complications, and 30 had
minor complications; therefore, there were 379 same-day discharges. It was determined that
these same-day discharges in this study saved $163,500. It was estimated that if their same-day
discharge policy were applied to their patients during this study, the costs saved would have
exceeded $443,000 (He et al., 2021).
Deyell et al. (2020) conducted a study from 2010 to 2014 evaluating same-day discharges
versus overnight observation atrial fibrillation ablation patients. Their study of 3,054 patients had
a readmission/complication rate of 7.7% in the same-day discharges (2,418 patients) versus
10.2% in overnight observation patients (636 patients). Field et al. (2021) performed an actual
work cohort study evaluating outcomes with catheter ablation patients. Their study included
1,610 same-day discharges and 4,637 overnight stay patients. They found no significant
difference in post-procedure complications, 2.7% versus 2.8%. Interestingly, they found no
significant difference in atrial fibrillation recurrence between the two groups, 10.2% versus 8.8%
(Field et al., 2021). Rajendra, Hunter, Morales, and Osorio (2020) looked at the implementation
of same-day discharges following catheter ablation for atrial fibrillation. In their study, several
factors played into candidacy for same-day discharge. Bleeding risk, medical history (congestive
heart failure, respiratory disease, planned future procedures, BMI), and home location all
determined candidacy/risk for their patients. Based on their criteria for low risk, there were 44

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patients planned for same-day discharge from April 2017-June to 2018. Of these patients, 41
were discharged the same day as planned. Two patients were monitored overnight for
observation, and one stayed by personal choice. The same-day discharge patients were contacted
the following day by a nurse, and no patients discharged the same day had readmission within 30
or 60 days (Rajendra et al., 2020).
A large prospective study by Nordin et al. (2021) looked at post-procedure complications
following catheter ablation of atrial fibrillation. Their study evaluated 5,414 patients from 2001
to 2020. Results of their study revealed that there was a total of 108 (2.0%) patients who had
significant complications following their ablation before discharge. These complications
included congestive heart failure, pericardial effusion, significant heart block, or transient
ischemic events. The study also found that 61 (1.1%) patients had minor complications, defined
as transient phenic nerve injury and groin site issues, including hematoma, pseudoaneurysm, and
bleeding. Patient factors associated with more complications included cardiomyopathy history,
significant valvular disease history, higher BMI, longer procedure duration, transient ischemic
attack/cerebral vascular accident history, and female gender. The researchers noted that most
complications occurred during the procedure or within six hours of the procedure being
completed. Based on the results, it was deemed safe to discharge most patients the same day if
patients had no complications within six hours post-procedure (Nordin et al., 2021).
Bartoletti et al. (2019) performed a study that looked at same-day discharge patients
following catheter ablation. Their study looked at patients from 2014-2017, and in that study,
169 patients were discharged on the same day. Their study identified 811 patients who were
morning cases for catheter ablation. In conclusion, they felt same-day discharge was safe and

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feasible in select patients and could have been utilized more in their population (Bartoletti et al.,
2019).
A study completed by Akula et al. (2020) evaluated the implementation of sameday discharge for catheter atrial fibrillation ablation patients. Their study found 426 patients after
a same-day discharge policy implementation. Of these 426, 374 (88%) were discharged the same
day as the ablation. The 51 patients were not discharged and stayed for observation for various
reasons—only 17 of the 51 stated for ablation-related issues. There were 15 who stayed for nonablation-related medical care, 14 who stayed due to their preference, and five who stayed for
late-in-day procedure completion. (Akula et al., 2020).
Steinberg et al. (2022) published a Journal of Cardiovascular Electrophysiology student on
“Patient-reported outcomes and costs associated with vascular closure and same-day discharge
following atrial fibrillation ablation." The study aimed to evaluate patient-reported outcomes and
costs associated with the vascular closure devices used and the same-day discharge following the
ablation. The authors used a retrospective chart review to collect data on patient demographics,
procedural characteristics, and patient-reported outcomes, including pain, swelling, discomfort at
the puncture site, and the length of hospital stay. The study results showed that using vascular
closure devices was associated with improved patient-reported outcomes, including reduced
pain, swelling, and discomfort at the puncture site. Additionally, patients who underwent sameday discharge and significantly shorter hospital costs.
The authors concluded that using vascular closure devices and same-day discharge
following atrial fibrillation ablation is associated with improved patient-reported outcomes and
decreased healthcare costs. They noted that these findings have important implications for
patient care and suggest that further research is needed to understand these approaches' benefits

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and limitations better and determine the best methods for optimizing patient outcomes and
reducing healthcare costs.
The overall safety, cost-effectiveness, patient acceptance, and feasibility of same-day
discharge following atrial fibrillation catheter ablation are consistent throughout the previously
discussed studies.
Chapter 3: Methodology
This research aimed to determine how same-day discharges impact the safety or clinical
outcomes and costs of patients undergoing these ablations.
The focus of this research study was atrial fibrillation catheter, ablation patients. Patients
who underwent catheter ablation for atrial fibrillation were evaluated and compared in this
program evaluation. The variable evaluated was same-day discharge versus observation/inpatient
status. The outcomes evaluated based on the phenomena included clinical outcomes and
complications, readmission at 30 days, and cost-benefit.
Research Methodology
The methodology determined for this research was quantitative.
Research Design
The method for this project involves a retrospective cohort analysis. Same-day discharge
was brought up as a potential process as the COVID-19 pandemic persisted. The facility studied
is a 480-bed hospital and tertiary-care medical facility in Erie, Pennsylvania. Four
electrophysiologist cardiologists are employed at the facility and involved in the research. The
population involved in this project were patients undergoing catheter ablation for atrial
fibrillation. Historically at this facility, patients undergoing catheter ablation for atrial fibrillation
would stay overnight for observation. The following morning, patients were discharged home if

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there were no overnight events or potential complications. Same-day discharge was proposed as
bed availability, and staffing issues made consistency difficult. The electrophysiology
department determined a process for same-day discharges like prior processes in other healthcare
systems.
In same-day discharge policies, numerous criteria must be met to be considered. Prior
research has used factors such as time or order of procedure, patient residence distance,
procedural complications, recovery condition, and physical assessment near discharge.
Generally, patients were the first or morning cases to be eligible for same-day discharge. Any
periprocedural complication or issue excludes patients from same-day discharge. Patients with
any issues post-procedure were usually not eligible for same-day discharge. These issues can
include symptoms, groin site complications, or patient preference.
Several factors were identified as inclusion criteria for eligibility for same-day discharges
at the facility studied. First, the patient was to be the first ablation case of the day. Generally,
there are multiple procedures performed by each physician daily. For patients to be considered
for same-day discharge, they had to be the first procedure of the day and in the morning. Second,
the patients had to be local to the area. The facility where data was collected is considered a
regional or rural facility. Many patients come from regional areas, often with distances as far as
150 miles. With the implementation of same-day discharge for electrophysiology procedures, the
distance limit was 30 miles from the facility to the patient's residence. Patients who would
otherwise be eligible for same-day discharge outside of distance were offered hotel stays outside
the facility. This allowed patients to leave if stable but be close if needed for return due to issues.
Each patient was monitored in the Post-Anesthesia Recovery Unit before returning to the
short-stay unit. Patients were monitored for 4-6 hours of bed rest. After 3-4 hours of bedrest,

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groin site suturing was removed, and bedrest continued for 1-2 hours. Following completion of
bedrest, patients were to ambulate halls with the reassessment of their groin site and assessed for
any symptom development. Post-procedure electrocardiogram was performed on all patients. If
patients had symptoms, limited echocardiography was considered or completed if indicated.
With no issues observed or voiced, patients were discharged home or to the hotel with family or
caregivers. Patient information was entered in a UPMC confidential log through Microsoft
Teams. This log was viewable by nurses in the office for reassessment post-discharge. Patients
were contacted by telephone by triage nursing staff or electrophysiology providers (physicians or
advanced practice providers) the following morning for reassessment, and documentation of this
call was completed in the electronic medical record.
The team members involved in the process include physicians, advanced practice
providers, electrophysiology lab registered nurses, recovery nurses, short-stay nurses, and
outpatient triage nurses.
As mentioned previously, this project was a cohort study to analyze the implementation
of a same-day discharge process. The expectation with this project was that same-day discharges
of catheter ablation patients would be a safe process to implement permanently. If patients met
specific criteria and were discharged, adverse outcomes were expected to be similar or less than
catheter ablation patients admitted for observation overnight in the hospital.
This study collected and analyzed data from July 2021 to July 2022. We collected data on
all atrial fibrillation catheter ablation patients for this project. This approach allowed for
extensive comparison amongst all patients of this population, regardless of the length of stay.
Having all the patient information with population allowed for comparison amongst same-day
discharge patients and comparison of same-day discharges versus overnight observation.

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Population and Sample Selection
This program evaluation occurred at a 480-bed hospital in northwest Pennsylvania in
Erie, Pennsylvania. The hospital is a tertiary care facility that is a level II trauma center. For this
evaluation, the general population was patients undergoing catheter ablation for atrial fibrillation.
The target populations included these patients who were discharged the same day as the catheter
ablation compared to the patients who were observed overnight or admitted as inpatients. These
patients had no specific geographic information that included or excluded them from the study.
The sample size for this project included 321 patients over 12 months, from July 2021 to
July 2022. This sample size is comparable based on prior studies that involved research on sameday discharges at single centers. In Chu et al. (2021) there was a sample size of 249 patients.
Bartoletti et al. (2019) had a sample size of 1,599 patients. This sample size was over three years,
from 2014-2017. Reddy et al. (2020) had a sample size of 448 patients over 13 months from
March 2017 to April 2018. Vaillancourt et al (2022) had a sample size of 727 patients. This
sample was collected from January 2019 to the end of December 2020. Deyell et al. (2020)
studied same-day discharge at two major tertiary centers in Canada from 2010 to 2014. Their
study reported that the average amount of atrial fibrillation catheter ablations performed at the
included facilities was around 300. This is consistent with the volume of catheter ablations
performed annually in this study’s facility.
Instrumentation
This study is a retrospective cohort study. Data were gathered through chart reviews
using diagnosis and procedure codes. UPMC Clinical Analytics was the program used to collect
and extract the data. Quality management at the facility created a SQL query within Xper IM, a
clinical data monitoring and information management program.

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Validity
There is validity to this evaluation given that the research topic variables were measured
and assessed as initially aimed. This project analyzed readmission rates, complications, and costs
in patients undergoing atrial fibrillation catheter ablations. The study accurately measures the
variables involved based on the results reported and collected. There is external validity given
that the results reported in this study appear consistent with other similarly designed studies.
There is internal validity as several team members were involved in the study design and data
collection similarly.
Reliability
The programs used in this study are available for widespread use. Microsoft Excel is a
part of most computing systems and is often used to analyze data collected. Xper IM is a
program used throughout hospital systems in cardiac procedure suites.
Data Collection and Management
Patient case data is entered and stored automatically in Xper, an information entry and
management program used in many cardiology procedure suites. The quality manager used this
program to extract patient data in the study. He created a SQL (Structured Query Language) in
the electrophysiology case reporting program using the term “afib ablation.” These cases'
account numbers were then used to extract visit information, including admission and discharge
dates. The data was then transferred to a Microsoft Excel spreadsheet for further organization.
Data Analysis Procedures
Using the collected data from Xper IM, which was organized in Microsoft Excel,
information was compared based on multiple characteristics. The pertinent data for comparison
in the total data included length of stay, age, gender, and complication.

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Ethical Considerations
In this study, there are minimal ethical concerns. The areas that need to be considered in
any research are safety, anonymity, confidentiality, and conflict of interest. As a retrospective
study, there are no risks to the patient from a safety perspective as the care and outcomes have
already occurred. As part of the informed consent process with the procedures, risks regarding
catheter ablation were discussed in detail with each patient. Each patient consented to treatment
with catheter ablation. This study did not impact the procedure or after that in any way. As part
of the informed consent process, patients consent to their procedure information to be used for
scientific and educational purposes. This allows for the information to be used in evaluations
such as this.
In this study, the data was collected initially using diagnosis and procedural codes. No
names or other identifiers were used; therefore, anonymity was maintained throughout the study.
Confidentiality was also maintained throughout the study. Data abstraction and analysis were
done and held on a company-protected device with protective firewalls. In addition, permission
was obtained through UPMC for this study. See Appendices.
Information and data obtained through this study are maintained in a Microsoft Excel
worksheet. The information obtained is part of the patient's records and is kept indefinitely.
Company firewalls protect the information. Related to this project, the information will be kept
for the duration of the study’s completion.
Limitations and Delimitations
Related to the evaluation methodology, there are several limitations in this study. One
limitation of this study is the timeframe. The same-day discharge process was initiated before
July 2021 and has continued since July 2022, so the timeframe could be more expansive.

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Another limitation is the procedure type. Same-day discharge is used in many types of
procedures in electrophysiology and other specialties. Another limitation is the length of followup. This study determined readmission rates at 30 days and 90 days. One could evaluate beyond
90 days in other research.
Summary
Chapter 4: Data Analysis and Results
This project aimed to evaluate using the same-day discharge process with patients
undergoing catheter ablation. The PICO question was, "What are the clinical and financial
benefits of same-day discharge in catheter ablation electrophysiology patients?" This
retrospective program evaluation compared same-day discharge patients versus observation or
inpatient patients over 12 months from July 2021 to July 2022.
In the process of a same-day discharge, eligible candidates were atrial fibrillation catheter
and ablation patients. These patients were the first scheduled procedure of the day. They were
monitored over 4-6 hours post-procedure. Finally, they had to have no complications periprocedurally and post-procedurally to be discharged home the same day. These patients were
then discharged home and contacted the following morning for reassessment. Patient information
was given to providers' teams for contact the following day, and these patients were entered into
a Microsoft Teams data group. In data collection, the Xper IM was used to populate all patients
who underwent atrial fibrillation catheter ablations in the 12-month period. This data was then
organized through Microsoft Excel worksheets which were then used to analyze the data. In this
project, it was hypothesized that the same-day discharge with catheter ablation patients would be
cost-effective and have similar outcomes related to readmission and complication rates as
patients admitted as an inpatient or observation status.

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Over the studied timeframe between July 2021 to July 2022, 321 atrial fibrillation
catheter ablations were performed. Demographically, the patient's age ranged from 25 years of
age to 84 years of age. The median age of the total population was 67 years old. There were 216
total male patients and 105 total female patients.

Catheter Ablation Patients

74

246

Same-day discharges

Overnight/Inpatients

The total of same-day discharges was 74 patients. This was 23% of the total atrial
fibrillation catheter ablation population over the studied timeframe. The median age of same-day

23

discharges was 66 years old. The oldest patient discharged the same day was 78 years old. The
youngest patient discharged the same day was 31 years old. There were 55 male patients
discharged the same day. There were 19 female patients discharged the same day. Of the sameday discharges, no complications were reported through follow-up calls the next day. Of those 74
patients, three were readmitted within 30 days of their procedure. 30-day readmission rate based
on this timeframe was calculated to be 4%. One of those patients was admitted for acute
congestive heart failure. Another patient was admitted with recurrent symptomatic atrial
fibrillation resulting in inpatient admission. The third patient was readmitted for pericarditis. The
patient readmitted for recurrent symptomatic atrial fibrillation was again readmitted within 90
days of the procedure due to acute congestive heart failure. One other patient was readmitted as
an inpatient within 90 days of the procedure for symptomatic atrial fibrillation. The 90-day
readmission rate for these same-day discharges was calculated to be 2.7%.
A total of 246 patients were admitted for observation or as inpatients following their
catheter ablation for atrial fibrillation. Out of these 246 patients, there four patients were
readmitted within 30 days of the procedure. Three of the patients were readmitted for acute
congestive heart failure. One patient was readmitted within 30 days due to recurrent symptomatic
atrial fibrillation. The 30-day readmission rate for observation/inpatient patients was calculated
to be 1.6%. Out of the 246 patients, there three patients were readmitted within 90 days of the
procedure. One patient was readmitted for noncardiac reasons that were unrelated to the
procedure. Another patient was readmitted due to symptoms of chest pain related to recurrent
atrial fibrillation. The third 90-day readmission was hospitalized due to sinus node dysfunction
and underwent a dual-chamber pacemaker implant. The 90-day readmission rate for these
patients was calculated to be 1.2%.

24

Readmission rate

Readmission Rate

OBS/INP at 90 says

OBS/INP at 30-days

SDD at 90 days
SDD at 30-days

0% 1% 2% 3% 4% 5%

0.00%

Readmission rate

1.00%

2.00%

3.00%

Readmission Rate

There was one patient out of the 321 procedures that died the same day as the procedure.
The patient underwent catheter ablation without documented periprocedural abnormalities or
complications. The patient went to the recovery unit. Several hours after the procedure, the
patient lost consciousness in the setting of ventricular fibrillation. Ultimately, the patient died
following multiple attempts of resuscitation.
Based on the reported cost savings with each same-day discharge, there was an estimated
cost savings of $37,000 with 74 catheter ablation patients. Costs were more than that with
patients admitted as inpatients. Based on this information, there was an estimated $123,000
additional cost related to overnight observations.
Chapter 5:
Discussion
Summary
As previous studies have shown, using same-day discharge in atrial fibrillation catheter
ablation procedures is safe, reliable, and cost-effective for appropriate patients. Studies are

25

continuing to be done regarding the safety and cost-effectiveness of same-day discharges for
many procedures, and most of them, have thus far shown that the process consistently is safe and
effective and yields similar results as traditional observations. This specific study looked at
catheter ablation patients at a northwest Pennsylvania hospital over 12 months to further review
this process. It was a retrospective study comparing same-day discharge patients to catheter
ablation patients admitted for observation or as inpatients. The PICO question for this study was,
"What are the clinical and financial benefits of using same-day discharge with patients
undergoing catheter ablation for atrial fibrillation?
Over 12 months, from July 2021 to July 2022, there were 321 catheter ablations for atrial
fibrillation. Of the 321 ablations, there were 74 same-day discharges and 246 patients admitted
for observation or as inpatients. One patient died the same day as their procedure.
Interpretation
A review and analysis of the data demonstrated that the 30-day readmission rate for these
patients was 2% for observation patients and 4% for same-day discharges. The 90-day
readmission rate was 1.2% for observation/inpatient patients and 2.7% for same-day discharged
patients. Outside of the patient who died, there were no major complications noted. No
procedural complications were documented. Readmitted patients had a recurrence of
symptomatic atrial fibrillation, acute congestive heart failure, and pericarditis. One patient
developed sinus node dysfunction resulting in a dual chamber pacemaker implant. With sameday discharge, the hospital had an estimated cost-saving of $37,000. This was based on an
estimated $500 per 12-hour cost for the hospital admission.
The cost for these admissions would result in a higher value than $123,000. In
comparison, there was at least an estimated $123,000 in extra costs related to patients staying

26

overnight for observation. This estimated cost does not include additional nights and additional
testing.
Based on the data in the study, it was accepted that there is no significant difference
between same-day discharges and admitted patients related to clinical outcomes. There was less
than a 2% difference in both comparisons. Related to the financial impact, there is a significant
difference between same-day discharge and admitted patients for observation or inpatient.
These results reinforce the safety and cost-effectiveness of same-day discharge with
patients undergoing catheter ablation. It is consistent with prior studies showing similar results
where same-day discharges save tens of thousands of dollars and have similar clinical outcomes
or readmission rates.

Limitations
Strengths of this research include sample size as it is similar sampling to comparable
studies. Also, the results are similar to comparable studies and reinforce the results and
conclusions. Weaknesses to this study and limitations could be related to timeframe and onset.
The onset of the same-day discharge process was initiated prior to July 2021. The timeframe can
raise concerns for bias as the study was performed after the onset of the same-day discharge
process. Therefore, further study could be done to strengthen the research by further evaluating
from the onset of the process to present practice.
Conclusions
This research study can be replicated and has been similarly performed elsewhere.
Ongoing research in this study would continue to reduce the risk of research imprecision, bias, or
confounding. Ongoing and future will take place involving catheter ablations and discharge

27

process. Further research can continue to cement same-day discharge as a safe, reliable, and costsaving process in healthcare. Future research can and should involve other electrophysiology
procedures and noncardiac procedures done with historical observation overnight. With costs
continuing to rise in healthcare, the use of same-day discharging following procedures is one
way of reducing costs and easing some burden on healthcare systems and workers.

References

28

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31

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Appendix A
Project Sponsor,

The Quality Improvement Review Committee is pleased to inform you that your QI project
has been approved.

We have also notified your local quality department of this approval and encourage you to
share updates on the project’s progress.

Please note that results of QI projects must be reviewed by local quality directors and
approved by the Chief Quality Officer prior to dissemination (via presentation or
publication) outside of UPMC. UPMC has adopted the Standards for Quality Improvement
Reporting Excellence guidelines, SQUIRE 2.0 as the suggested reporting format.

For multicentermulticenter projects, the QRC approval refers only to that part of the
project being performed at UPMC facilities and the sponsors are responsible for
obtaining approval from other non UPMC facilities participating in the project.

We suggest that you share your findings on this project with the QRC. When your project is
complete, please navigate to the Quality Improvement Project Portal via MyApps or UPMC

33

Network and go to “My Projects.” Select the project and go to the “Project Summary” tab,
add the findings in the “Project Results” field, and click “Submit Project Results to QRC.”

Projects reviewed and approved by the UPMC Quality Improvement Review Committee do
not meet the federal definition of research according to 45 CFR 46.102(l) and do not
require additional IRB oversight.

Project Submission Details:
Project ID: 4065
Project Title: What are the financial and clinical benefits of same-day procedural
discharges in electrophysiology patients? A retrospective study evaluating same-day
discharges versus traditional observation overnight patients.
Project Sponsor:
Matthew Hodas ** CRNP, Senior ** RHS00-UPMC Hamot HeartVascular
Project Co-Sponsor(s):
Deborah Pora ** Clinical Project Director, CVT ** HAMOT-Admin Cardio Pulmonary
Madhurmeet Singh ** Physician ** RHS00-UPMC Hamot HeartVascular
Jay Williams ** Quality Manager ** HAMOT-Admin Cardio Pulmonary
Submitted By:

34

Matthew Hodas ** CRNP, Senior ** RHS00-UPMC Hamot HeartVascular

Additional Information from the QRC: This is an excellent project - I am excited to see
your results!

To view the full project, log in to the Quality Improvement Project Portal via MyApps or
UPMC Network, click on “My Projects,” and select project.

Thank you for submitting your project for our review

Eric J. Dueweke, MD, MBA, FACC
Cardiologist and Clinical Lecturer
Medical Advisor, UPMC Quality Improvement Review Committee (QRC)
UPMC Heart and Vascular Institute

E-mail: duewekeej@upmc.edu

35