Reduce hospital stay for stent patients by 5 days
Reduce hospital stay for stent patients by 5 days
Change anti-clotting medication to cut costs
Cardiac care patients who received stents at Columbia (SC) Providence Heart Institute had a five- to seven-day length of stay two years ago.
Now the same type of patients are sent home between 24 and 32 hours following surgery. They produced these markedly improved results by changing the type of medication used to prevent blood clotting, says Mark Scott, director of the catheterization lab at the hospital.
"We were too aggressive in our blood-thinning approach," Scott explains.
One drawback of stents is that the devices provide "an excellent surface for blood clots to develop," Scott says.
So doctors prevented the blood clots from forming through the use of anticoagulants. The problem was that the drugs can cause strokes and hemorrhaging in tissues or organs after surgery.
Providence and other hospitals have reduced lengths of stay by switching from aggressive anticoagulants to a combination of aspirin and ticlopidine hydrochloride, which is manufactured by Roche Laboratories of Nutley, NJ, under the name Ticlid. It’s a platelet aggregation inhibitor.
The Kettering (OH) Medical Center also uses the aspirin-ticlopidine combination after first giving stent patients Heparin, an aggressive anticoagulant. Heparin is manufactured by Wyeth-Ayerst Laboratories in Philadelphia.
"We use Heparin at the time of the procedure and keep their activated clotting time fairly high, and then we let that come down gradually," says Jeff Morneault, MBA, manager of cardiac diagnostic and treatment services at Kettering.
Kettering’s physicians switch to the aspirin-ticlopidine combination after the procedure, when the patient is stabilized, Morneault says.
When stents first came out in the late 1980s, doctors found that many patients developed acute thrombosis (blood clots on the stents), says Roger J. Laham, MD, of Beth Israel Hospital in Boston and an author of a recent study published in the Journal of the American College of Cardiology, about the successful long-term use of stents.need a reference.
"When we started studying it, we used every possible medication to do that," Laham says. "We used aspirin, Coumadin, Dextran, and Heparin. This cut down the acute thrombosis from 20% to 10% to less than 5%."
Initially, many Beth Israel stent patients were given Coumadin, an anticoagulant manufactured by DuPont Pharma of Wilmington, DE, explains Donald S. Baim, MD, a heart surgeon with Beth Israel Hospital, who also was involved in the Boston study.
"So whereas patients would stay in the hospital over one night during a two-day hospital stay, they’re now going home on just antiplatelets-type medicines, without Coumadin," Baim says.
Hospital used process of elimination
Laham says the hospital eliminated one anticoagulant after the other and finally was left with the aspirin-ticlopidine combination that is used with elective stenting procedures.
Aspirin and ticlopidine provide the lowest stent thrombosis rate, Laham says.
A German study published in the April 1996 issue of The New England Journal of Medicine compared the use of combined antiplatelet therapy with ticlopidine plus aspirin with conventional anticoagulant therapy of intravenous heparin, phenprocoumon, and aspirin.
The study of 626 patients found that the ticlopidine plus aspirin group had no severe hemorrhagic events and fewer peripheral vascular events. However, the group that received the traditional anticoagulant therapy had severe bleeding during all phases of the therapy. Twelve of these patients received blood transfusions, and two required surgery: one for gastric bleeding, and one for groin complications.
Morneault says cardiac administrators might not have to worry about using blood thinners at all in the next few years because researchers are developing new stents that are coated to prevent clotting.
"You can put the stents in and not have to worry about them too much," he adds. "But that’s a few years away."
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