The overview of most of literature investigating the issue of safety and feasibility of early discharge in AMI patients shows variable methodology and this explains that guidelines for early discharge are based just on limited data derived from randomized trials. The issue of early discharge was investigated in PRAGUE 5 study, which after pilot phase randomized 56 low-risk probands with STEMI, discharged even the next day after successful PCI. It was the first study in which mean length of hospital stay was shorter than 72 h . Most of the studies concerned with early discharge developed practical score for risk stratification of their AMI patients to identify the patients with low risk of subsequent complications who do not require extensive in-hospital monitoring and observation [17,18,19].
It has been proven that substantial reduction in-hospital length of stay has been associated with reduction of in-hospital charge  with no increase in post-discharge mortality . Some authors in previous studies concluded that patients with low risk of subsequent complications can be safely discharged within 2 days following primary PCI [5, 7,8,9], but it is important to focus on the fact that shorter hospital stay limits time for appropriate patient rehabilitation and education. Thus, the clinical follow-up post-early discharge should be carried out to assess safety.
Our center is the only cardiac center in the region providing tertiary care facilities and receives a huge number of AMI patients especially during the 2 to 3 weeks of hajj seasons, subsequently this puts a big burden for the required provided service and hospital costs. The primary aim of our study is to create and implement successful safe early discharge program to improve bed’s utilization efficiency and provide the best, safe, and maximum service for cardiac patients during over crowdedness of the hajj season. To the best of our knowledge, there are no similar studies conducted in our region concerned with this idea. We selected few weeks of each hajj season to conduct this study for many reasons: First, as previously mentioned, our cardiac center is the only center in the region of Makkah that has cath lab facilities and this required to provide tremendous tertiary care services to pilgrims and residents of Makkah during hajj season. Therefore, appropriate improvement of bed utilization is crucial with subsequent increase of hajj population in the successive years. Second, during this selected period, most of our AMI patients were pilgrims who had special ritual, religious emotions, and soul as most of them were doing their hajj for the first time having beliefs that longer hospital stay might reduce the opportunity to complete the hajj for which they were coming and persistently asking all the time for discharge. We believe that appropriate early post AMI discharge might grant their wishes provided it is totally safe. Third, during this short 2 weeks of hajj season additional two millions of population increase within Makkah city from pilgrimage and this requires a huge health service demand. Many facilities provided by the Ministry of Health and Hajj Committee during hajj seasons to provide a tremendous 24 h non-stop cardiac services included increasing manpower, raising number of working cath labs, improving working network, expanding all available services, and hence all that motivate the huge work and discharge of stable cases. We started implementation of early discharge program on hajj season 2018 and continued on 2019 to enlarge our sample size, which might help to gather more data and generalize our conclusion.
Our results concluded that those early discharged patients had higher percentage of pilgrims who were in high need for early discharge to compete their hajj pillars with their groups and return back to the their home countries safely. They also showed to have low-risk AMI features including less prevalence of cardiovascular risk factors and comorbidities, which all might predict safe early discharge post revascularization. Early revascularization with PPCI with appropriate target for DBT (door to balloon time) was recorded higher among those early discharged patients and this reflects higher quality of service provided by our center to AMI patients and could help in the process of early discharging them from the hospital. Clinical features and short-term outcome of AMI patients post event are crucial once decided the discharge process and these were followed carefully during our program implementation (early discharged patient had lower Killip class and higher post myocardial infarction LV ejection fractions). Reassuringly, most of our early discharged patients had favorable coronary artery disease anatomy (lower prevalence of both left main and multi-vessel disease) and this encouraged their early discharge process.
Follow-up data results were impressive as majority of our early discharged patients were totally asymptomatic (95%). Few percentages of those patients had non-serious symptoms and did not require any major intervention and this might reflect the early success of implementation of such program in our facility, which is considered the corner stone in the region.
Finally, our current experience reflects many advantages: great compensation of the huge required hospitalization burden; provision of the best, safe, and maximum service for cardiac patients during over crisis periods; lower hospital cost; and improvement of patient’s satisfaction.
Our study is limited to a single center and relatively small population number (short period selected only two hajj seasons) corresponds to the conclusions of mentioned studies. There are many factors explaining limitation of our follow-up data (as 40% of our early discharged patients lost their follow-up): language barrier, wrong written contact number in our records, non-attending calls, and higher percentage of those patients were pilgrims who returned back to their countries immediately after hajj without any follow-up here. We tried to support our results with some previous randomized studies with such recommended strategies and shorter length of hospital stay.
We hope to reduce these limitations in future seasons by the following suggestions:
Suggested plan to establish proper educational program with help of the health promotion department supported with different language materials, which will be provided to those patients during their hospitalization regarding to their disease process, medication compliance and proper short-/long-term follow-up
Proper recording of correct contact numbers of the patients organized by our admission office and bed management departments
Motivation of the primary and secondary hospitals in the regions to conduct similar programs and possible organization of better follow-up protocols