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Randomized Controlled Trial
. 2014 Aug;64(2):167-75.
doi: 10.1016/j.annemergmed.2013.10.029. Epub 2013 Nov 13.

Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission

Benjamin C Sun  1 , Heather McCreath  2 , Li-Jung Liang  2 , Stephen Bohan  3 , Christopher Baugh  3 , Luna Ragsdale  4 , Sean O Henderson  5 , Carol Clark  6 , Aveh Bastani  6 , Emmett Keeler  7 , Ruopeng An  8 , Carol M Mangione  9
Affiliations
Randomized Controlled Trial

Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission

Benjamin C Sun et al. Ann Emerg Med. 2014 Aug.

Abstract

Study objective: Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes.

Methods: This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction.

Results: Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction.

Conclusion: An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.

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Figures

Figure 1
Figure 1
Risk Stratification Guidelines
Figure 2
Figure 2
Screening and Enrollment Flowchart
Figure 3
Figure 3
Kaplan-Meier Curves for Safety Events
See this image and copyright information in PMC

References

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    1. Linzer M, Yang EH, Estes NA, 3rd, Wang P, Vorperian VR, Kapoor WN. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997;126(12):989–996. - PubMed
    1. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation. 2006 Jan 17;113(2):316–327. - PubMed

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